Strategic planning for health: a case study from Turkey Strategic planning for health: a case study from Turkey PREFACE This report was prepared as part of the ongoing collaboration

Strategic planning for health: a case study from Turkey

Strategic planning for health: a case study from Turkey

By: Anne S. Johansen

ABSTRACT

This report explores the role of strategic planning in Turkey’s successful transformation of its health sector since 2002. It analyses the evolution of strategic planning for health from an informal tool to an official and highly structured process that closely follows the steps identified in accepted models of strategic planning.

The report also analyses the process employed to prepare Turkey’s strategic plans for health, as well as their contents, including the vision for Turkey’s health system, the Ministry of Health’s mission, strategic goals, objectives and the monitoring and evaluation framework with its indicators and targets.

In addition, the report documents that Turkey’s most recent strategic plan, Strategic Plan 2013–2017, is an example of the new European policy framework – Health 2020 – put into practice at the country level. It therefore serves as an role model for other countries wishing to develop their strategic planning capacity.

KEYWORDSHEALTH PLANNINGHEALTH SYSTEMS PLANSPUBLIC HEALTHTURKEY

Address requests about publications of the WHO Regional Office for Europe to:

Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark

Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest).

© World Health Organization 2015All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full.The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization.

Design and layout by Phoenix Design Aid A/S, CO2 an ISO 14001 (environmental management), and DS 49001 (Corporate Social Responsibility) certified and approved CO2 neutral company – www.phoenixdesignaid.com.

V

CONTENTS

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .VI

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VII

Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .VIII

Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .IX

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2. Data and information sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

3. Turkey before and after the Health Transformation Programme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

4. Strategic planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

4.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

4.2 A brief history of strategic planning in the public sector in Turkey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

5. Structure and content of Turkey’s strategic plans for health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

6. Evolution of strategic planning for health in Turkey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

7. Analysis of the evolution of strategic planning for health in Turkey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

8. Strategic planning and health system performance in Turkey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

8.1 A sound standard for national strategic health plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

8.2 Assessment of Turkey’s strategic plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

9. Recommendations for the continued development of strategic planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

10. Lessons learnt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

11. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Annexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Annex 1. Reforms and health system strengthening initiatives (2003–2013) . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Annex 2. Bryson’s strategic planning model applied to the Health Transformation Programme (2003–2009) . . . 36

Annex 3. Comparison of Turkey’s strategic plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Annex 4. Strategic Plan 2013–2017 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

VI Strategic planning for health: a case study from Turkey

PREFACE This report was prepared as part of the ongoing collaboration between the WHO Regional Office for Europe and the Ministry of Health of Turkey, which among other objectives serves to analyse and share lessons learnt from its health sector transformation during the past 12 years. Previous reports have explored Turkey’s progress on tobacco control (Tobacco control in Turkey: story of commitment and leadership) and analysed the design of the reforms and the strategic way in which they were implemented (Successful health system reforms: the case of Turkey).

This report explores more broadly the role of strategic planning in this transformation, and how it has evolved from an informal tool to an official and highly structured process, closely following the steps identified in accepted models of strategic planning. Turkey has prepared two first-rate strategic plans. The most recent one, Strategic Plan 2013–2017, was closely supported by the Regional Office.

Turkey’s Strategic Plan 2013–2017 is noteworthy for several reasons. First, it is an example of how to operationalize the new European policy framework, Health 2020, at the country level. This framework, which aims to “significantly improve the health and well-being of populations, reduce health inequalities, strengthen public health and ensure people-centred health systems that are universal, equitable, sustainable and of high quality”, emphasizes the need for action across government and society. The importance attached to multisectoral action in Turkey’s second health strategy is therefore particularly striking. Second, the plan shows Turkey’s clear commitment to the principles of the Tallinn Charter: Health Systems for Health and Wealth. And last, but not least, this plan, in many ways, conforms as a sound reference for strategic plans.

VII

ACKNOWLEDGEMENTS This report was implemented through the fruitful collaboration between the Ministry of Health of Turkey and the WHO Regional Office for Europe.

This study was carried out during the mandate of Mehmet Müezzinoğlu, Minister of Health of Turkey.

Yasin Erkoç, Deputy Undersecretary of the Ministry of Health of Turkey, led the preparation of the Strategic Plan 2013–2017, which forms the basis for this study.

Overall guidance for this study was provided by Hans Kluge, Director, Division of Health Systems and Public Health, WHO Regional Office for Europe; and Maria Cristina Profili, WHO Representative and Mehmet Kontas, Deputy Head of Country Office, of the WHO Country Office, Turkey.

Appreciation goes to all those who contributed to the elaboration of this case study from the Ministry of Health of Turkey, especially Yasin Erkoç for his invaluable opinions and recommendations; Songül Doğan, Head of Department, General Directorate of Health Research; Ömer Recep Aras, Ministry Advisor; Fatma Sevil Taner, International Relations Consultant, General Directorate of Health Research and Esra Kilicoglu, Reporting Specialist, General Directorate of Health Research. Appreciation is also expressed to those key people and actors who contributed with their insights about the health reforms in Turkey.

Anne S. Johansen, WHO Temporary Advisor, authored the document. Juan Tello, Programme Manager, Health Services Delivery, Division of Health Systems and Public Health at the WHO Regional Office for Europe reviewed the methodology and technical contents of the study. Belinda Loring, National Health Strategies and Plans Technical Officer, Division of Policies and Governance for Health and Well-being at the WHO Regional Office for Europe provided input to the technical contents of the study.

VIII Strategic planning for health: a case study from Turkey

ABBREVIATIONS HFA-DB European Health for All database

HTP Health Transformation Programme

IHP+ International Health Partnership

JANS joint assessment of a national health strategy

M&E monitoring and evaluation

NHSP national health strategies and plans

SO strategic objective

SP0 Strategic Plan zero, the HTP 2003–2009

SP1 Strategic Plan (2010–2014)

SP2 Strategic Plan (2013–2017)

SWOT strengths, weaknesses, opportunities and threats

IX

EXECUTIVE SUMMARY1

INTRODUCTION

This report explores the role of strategic planning in Turkey’s successful transformation of its health sector since 2002, when the 59th Government of Turkey took power. The specific objectives of the report are to:

document a country example of strategic planning in the health sector; understand the factors that made strategic planning for health in Turkey so successful; explore ways in which strategic planning in Turkey might be strengthened; and identify lessons learnt from Turkey’s experience for other countries wishing to strengthen their strategic

planning capacity.

Information and data for the report come from a combination of sources: published reports and articles available in print or on the internet; semi-structured interviews with key-informants; minutes of stakeholder meetings held in July 2012; and data from published reports, the WHO European Health for All database and data provided by the Ministry of Health of Turkey.

TURKEY BEFORE AND AFTER THE HEALTH TRANSFORMATION PROGRAMME

The health system was in poor shape when the new Minister of Health, Professor Recep Akdağ, took office on 18 November 2002. Health indicators, such as life expectancy and infant mortality, were among the lowest in the WHO European Region and out-of-pocket expenditure was high. Not surprisingly, the population rated their satisfaction with the health system very low. Ten years later, the health system had been transformed and all aspects of health system performance had improved sharply from health indicators to financial protection to population satisfaction.

These achievements were the results of decisive political action and effective reforms that addressed the myriad root causes of the performance problems. Of course, the strong economic growth experienced in Turkey since 2002 and the political stability that ensued greatly facilitated the ability of the Ministry of Health to implement its reforms; however, a detailed discussion of these factors is beyond the scope of this report.

The Minister of Health moved quickly to tackle the problems facing Turkey’s health system, publishing an emergency plan shortly after taking office. This plan identified 11 strategies designed to transform the Turkish health system. The Health Transformation Programme (HTP), based on these strategies, was initiated in early 2003. The aim of HTP was to develop a primary health care-based delivery system with universal access through a unified social insurance system for all residents in Turkey. The system would be re-organized and strengthened on a number of fronts (e.g., human resources, equipment, medicines, information technologies) to improve both the efficiency and quality of care.

Implementation began immediately and was performed in a very strategic manner, with easy changes made first, which helped build credibility and contributed to continued political support for the more difficult reforms, which were

1 This section does not contain references as they are included in the main body of the report.

X Strategic planning for health: a case study from Turkey

more time consuming. But the strategic approach of the Minister and his team went considerably beyond the mere sequencing of reforms. Indeed, as the analysis in this report shows, strategic planning played an important role in the success of the HTP.

STRATEGIC PLANNING FOR HEALTH IN TURKEY

Before proceeding with the discussion of the role of strategic planning for health in Turkey, clarifying how the term is used in this report is important. In the context of national strategic health plans, there is little agreement about the definition of terms like policies, strategies and plans, and the terms are frequently used interchangeably. This report uses the following definition for strategic planning: the process of envisioning a future and translating this vision into defined goals, objectives, strategies, tactics, and making resource allocation decisions in pursuit of these objectives.

Although the first official strategic plan for health was not published until 2010, the roots of strategic planning originate in Public Law No. 5018 on Public Financial Administration and Control, passed in 2003. Article 9 of this law mandates that all public administrations prepare strategic plans; it also directed that they base their budgets and resource allocations on these plans. However, the law failed to identify who would be responsible for the preparation of the strategic plans. Until this flaw was rectified at a later date, no formal strategic plans were prepared.

The absence of a formal mandate did not, however, prevent the Ministry of Health from approaching the design and implementation of the HTP in a manner that closely resembled strategic planning. Indeed, virtually all the steps and principles outlined in traditional strategic planning models were employed by the Ministry, with the exception of an extensive consultative process with stakeholders and the publication of an official plan, which would have significantly delayed implementation of the HTP. Thus, even in the absence of a formal plan, strategic planning played an important role in the HTP.

But equally important was the fact that strategic planning was embedded in a broader strategic management approach promoted by the Government of Turkey. As a result, strategic planning was accompanied by strategic implementation and strategic control (monitoring and evaluation processes). Reflecting this approach, when the Government of Turkey implemented the mandate that all public administrations prepare strategic plans, it issued regulations that required each plan to consist of sections on strategic analysis, strategic design and strategic implementation, as well as monitoring and evaluation. To ensure that the plans would also comply with high-level policies (both domestically and internationally), they also had to contain a section on the relevance of the strategic plan to high-level policy. The plans also had to be developed with extensive consultations with a wide array of stakeholders. These requirements were reflected in the preparation and content of the first formal strategic plan for health, published in 2010 (Strategic Plan 2010–2014), as well as in the second plan, prepared in 2012 for 2013–2017, to reflect the new roles and responsibilities of the Ministry established by Statutory Decree No. 663 issued in 2011.

XI

SUCCESS FACTORS OF TURKEY’S STRATEGIC PLANNING FOR HEALTH

Strategic planning for health in Turkey has been successful for a number of reasons. Conceptually speaking, there are two sets of reasons. The first has to do with the characteristics of the strategic plans and the way in which they were prepared, and the second with the way in which they were operationalized. As discussed above, the first strategic plan – the HTP from 2003–2009 – was not a full-fledged strategic plan, yet came quite close and provided achievable and realistic goals along with the necessary directions (strategies) for achieving them. It was not externally led, so the Ministry had full ownership of the plan. In short, it avoided three common pitfalls of strategic plans: a wish list (as opposed to a strategy); not including concrete, operational and realistic goals; and not taking full ownership.

The Ministry of Health was very strategic in its use of strategic planning. It did not invest to first build its capacity to prepare formal strategic plans, which would have been time consuming, but rather built that capacity incrementally in line with the new roles and responsibilities of the Ministry. The increased capacity is reflected in the evolution of the quality of the strategic plans over time, which has evolved from informal plans to formally endorsed plans prepared with wide stakeholder consultations. Indeed, the most recent strategic plan in many ways is a sound reference for strategic plans. This reference is based on a standard developed by an international partnership of international organizations, countries and other development partners (International Health Partnership), to assess strategic plans in low-income countries, and contains a number of attributes and criteria that almost all apply equally to strategies developed by middle- or high-income countries. On the vast majority of these attributes and indicators, Turkey’s strategic plan fulfils the expectations.

The second reason why strategic planning has been so successful is that it was embedded in a broader strategic management framework that paid equal attention to implementation and to monitoring and evaluation (M&E). As a result, plans were turned into actions that were piloted and tested before they were scaled up nationally. Furthermore, implementation teams on the ground provided not only support to the implementing agencies, but also direct feedback to the senior management in the Ministry of Health, which then took action to address systemic problems. In addition, a strong M&E system was put in place and progress was followed very closely with action plans developed as soon as problems were identified.

RECOMMENDATIONS FOR TURKEY’S CONTINUED DEVELOPMENT OFSTRATEGIC PLANNING

The analysis in this report shows that strategic planning has been not only successful, but also that the capacity to plan has been evolving over time. In order to increase the effectiveness of the strategic planning, it would be beneficial to create a closer link between the strategic planning process and the health systems performance assessment process. Furthermore, future strategic plans would be well served by expanding the situation analysis to go beyond the mandated strengths, weaknesses, opportunities and threats (SWOT) analysis, preferably by expanding the content of the “Strategic Issues” section of the strategic plans to include a root-cause analysis, which would form the basis for identification of the strategic issues that the organization (and the strategic plan) has to address.

XII Strategic planning for health: a case study from Turkey

LESSONS LEARNT

Turkey’s experience with strategic planning holds a number of lessons for other countries wishing to strengthen, or begin, their own strategic planning. First, strategic planning should only be done as part of a broader strategic management process where as much attention is paid to (strategic) implementation and (strategic) control as to planning.

Second, the situation analysis should go beyond the traditional SWOT analysis and include a careful diagnosis of the root causes underlying the observed performance problems in order to identify possible reforms or other health system strengthening initiatives that will need to be carried out, if the performance is to improve.

Third, for countries wishing to use strategic planning as part of an effort to transform their health sector, it should be emphasized that political leadership both within the Ministry of Health and from the top level of the Government of Turkey was a critical element of the success of the HTP. Without appropriate top-level political support, it may not be possible to carry out difficult reforms.

Finally, in health systems with a great degree of mistrust between key stakeholders, it may be better to identify quick wins that can help develop trust among the stakeholders who are also needed to carry out the more difficult reforms.

CONCLUSIONS

Turkey has succeeded in transforming its health system and achieved impressive health gains. This report documents the important role strategic planning has played in this success, but it is important to note that strategic planning in Turkey was part of a wider framework of strategic management, which included both strategic implementation and strategic control (M&E).

Traditional models of strategic planning include a large number of steps and the inclusion of many stakeholders in the process, which is quite time consuming. The Ministry of Health in Turkey ingeniously used the essential aspects of strategic planning to get the HTP off the ground quickly, and then used early successes to build the political support necessary to complete the more difficult reforms. At the same time, it developed the capacity to prepare full-fledged and officially approved strategic plans that involve a myriad of stakeholders and incorporate their feedback into the plan. Today, Turkey’s strategic plan comes close to what might be defined as the sound reference for such plans.

1

1. INTRODUCTION The Ministry of Health of Turkey recently published its second national strategic health plan covering the years 2013 – 2017 (Ministry of Health, 2012a). In its effort to become a role model for other countries – Objective 4.6.3 of this plan – the Ministry is keen to share its experience with strategic planning and lessons learnt that may be of use for other countries wishing to improve their strategic planning capacity. But solely investigating the most recent strategic plan would miss important lessons and fail to put it into the context that is required to understand its structure, content and success. This report therefore explores strategic planning since 2002 when the 59th Government of Turkey took power.

The specific objectives of the report are to: document a country example of effective strategic planning in the health sector; understand the factors that made strategic planning for health in Turkey successful; explore ways in which strategic planning in Turkey might be strengthened; and identify lessons learnt from Turkey’s experience for other countries wishing to strengthen their strategic

planning capacity.

The remainder of this report is divided into 10 sections. Section 2 provides an overview of the data used to prepare the report. Section 3 describes the health system before and after the Health Transformation Programme (HTP), which was developed to dramatically improve health system performance (Akdağ, 2011). Section 4 provides background information about strategic planning in general, as well as in Turkey. Section 5 explains the structure and content of Turkey’s strategic health plans while Sections 6–7 describe and analyse the evolution of strategic planning for health in Turkey. Section 8 explores the reasons for Turkey’s success in strategic planning and Section 9 offers suggestions for continuing this positive evolution of strategic planning. Section 10 lessons learnt and Section 11 concludes the report.

2. DATA AND INFORMATION SOURCES The information and data for this report come from a combination of sources:

published reports and articles available in print or on the internet; semi-structured interviews with key-informants; minutes of stakeholder meetings held in July 2012 (Ministry of Health, unpublished data, 2012); and data from published reports, the WHO European Health for All database (HFA-DB) (WHO Regional Office for

Europe, 2014) and data provided by the Ministry of Health.

Interviews with key informants from the Ministry of Health and relevant public organizations (e.g., Turkish Public Hospital Institution, the Ministry of Development) were carried out from 8 to 13 December 2013. To the extent possible, interviewees who were involved in the strategic planning process for the most recent strategic plan were selected.

The statistical data used in Section 3 derive from the WHO European HFA-DB, the Ministry of Health of Turkey and the Turkish Statistical Institute. Where the most recent data (2012) have not yet been reported by Turkey to HFA-DB,

2 Strategic planning for health: a case study from Turkey

this information was complemented by the Statistical Yearbook of the Ministry of Health of Turkey (2012) or other national reports. The validity and quality of the data deriving from national sources have not been checked by WHO and should thus be interpreted with caution by taking into account other HFA-DB related indicators. Such data and their publication in this document do not constitute an endorsement by WHO.

3. TURKEY BEFORE AND AFTER THE HTP The health system was in poor shape when the new Minister of Health, Professor Recep Akdağ, took office on 18 November 2002. Health indicators such as life expectancy, and infant and maternal mortality were among the lowest in the WHO European Region (WHO Regional Office for Europe, 2012b). Out-of-pocket expenditures were high and rates of satisfaction low. Despite years of analyses and discussions about reforms and a broad consensus about the general direction of needed reforms, the health system remained seemingly stuck with poor health outcomes and unhappy citizens (WHO Regional Office for Europe, 2012b).

The new Minister of Health faced many challenges. The health system was bureaucratic, inefficient, ineffective and inequitable. Primary health care was limited; there were few human resources for health and quality of care was poor. On the financing side, there was a fragmented health insurance system, limited risk pooling and low financial risk protection (Akdağ, 2012). With several different social health insurance systems and a limited Green Card Programme for poor people, benefit packages varied significantly. The different insurance schemes (as well as the military and the police) operated their own systems of health facilities, creating a fragmented delivery system that delivered care of highly variable and mostly poor quality. Dual public/private practice was widespread among physicians and productivity in the public sector was low (Akdağ, 2012).

Ten years later, the health system showed significant improvements. Table 1 shows that health system performance had increased dramatically between 2002 and 2012 (the latest year for which data are available). Life expectancy at birth had increased from 72.5 (in 2002) to 76.8 years (in 2012), an increase of 5.9%; maternal mortality had dropped from 64.0 to 15.4 per 100 000 live births between 2002 and 2012, a decline of more than 75%. Infant and under 5 mortality rates had also fallen sharply, allowing Turkey to meet the Millennium Development Goal to reduce child mortality before the 2015 target date. Domestic measles and malaria had been virtually eliminated, and the incidence of tuberculosis had been reduced from 27.3 to 18.7 per 100 000 population. Smoking rates (daily smokers) had also declined by more than 25%.

During the same time, financial risk protection had increased significantly with health insurance coverage rates increasing by more than 20% while total health expenditures, as a percentage of gross domestic product, had increased by only 0.6%.

Equally impressive is the tremendous increase in general satisfaction with health services, which may be a reflection of the increased health care utilization during this period. Total per capita visits to a physician (at all levels of care and across all sectors) rose by 164.5%. This increase in utilization was enabled in part by a major investment made in human resources, which rose by an estimated 84.5%.

3

Year

Indicator 2002 2009 2012

Health

Life expectancy at birtha 72.5 76.1 76.8 5.9

Maternal mortality ratio per 100 000 live birthsbc 64.0 18.4 15.4 -75.9

Birth in health care institutions (%)b 75.0 91.0 97.0 29.3

Infant mortality rate per 1000 live birthsbc 31.5 10.2 7.4 -76.5

Under 5 mortality rate per 1000 live birthsbc 40.0 14.1 11.0 -72.5

Diptheria, acellular pertussis and tetanus (DaPT3) vaccination ratio (%)b 78.0 96.0 97.0 24.4

Communicable diseases

AIDS incidence per 100 000d 0.07 0.1 0.13 85.7

Measles incidence per 100 000a 11.8 0.1 0.12e -99.0

Tuberculosis incidence per 100 000a 27.3 23.3 18.7 -31.5

Malaria incidence per 100 000a 15.5 0.1 0.5f -96.8

Risk factors

Daily smokersa 32.1g 27.4h 23.8 -25.9

Overweight (25 ≤ body mass index < 30) (%)ijk NA 33.0l 34.8 5.5m

Obese (body mass index ≥ 30) (%)ijk NA 16.9l 17.2 1.8m

Financial risk protection

Health insurance coverage (%)n 70.0 95.9 98.3 40.4

Total health expenditure (% of gross domestic product)b 5.4 6.1 6.5 20.4

Public health expenditures (% of total health expenditures)n 70.7 80.9 76.8 8.6

Out-of-pocket health expenditures (% of total health expenditures)b 19.8 14.1 15.4 -22.2

Satisfaction

General satisfaction with health services (%)b 39.5g 65.1 74.8 89.4

Health services delivery: inputs

No. physicians per 100 000ao 138 164 172 24.6

No. nurses and midwives per 100 000ai 171 213 249 45.6

Total human resources for health (all categories and sectors)b 378 551 609 900 698 518 84.5

No. hospital beds per 10 000a 24.8 26.0 26.5 6.9

No. intensive care bedsa 2214 16 020 23 689 970.0

No. ambulancesb 2963 4658 4269 44.1

Health care utilization

Total per capita visits to a physician (all levels of care and sectors)ai 3.1 7.3 8.2 164.5

Total hospital visits per capitaai 1.9 4.7 5.1 168.4

TABLE 1. SELECTED HEALTH SYSTEM PERFORMANCE INDICATORS (2002, 2009 AND 2012)

Change2002–2012

(%)

NA: not available;

a Ministry of Health, 2013a;

b Ministry of Health, 2012b;

c Akdag, 2012;

d WHO Regional Office for Europe, 2014;

e 2011 data;

f Imported cases or relapsing cases; no new cases of malaria;

g 2003 data;

h 2008 data;

I Population estimations for 2002–2006 were re-calculated by Turkey Statistical

Institute and the Ministry of Health. Thus some indicators in 2002 differ from

those reported by the Ministry of Health (2013a);

j 2010 data;

k Turkey Statistical Institute, 2013;

l Turkey Statistical Institute, 2012;

m Percentage change calculated for 2009–2012;

n Ministry of Health, 2012a.

o Author’s calculation based on data from Turkish Statistical Institute (2014).


These results came from decisive political commitment to reform and immediate action taken to transform the health sector. Of course, the strong economic growth experienced in Turkey since 2002 and the political stability that ensued facilitated greatly the ability of the Ministry of Health to implement its reforms. However, a detailed discussion of these factors is beyond the scope of this report.

The Emergency Action Plan of the 58th Government, which under the heading Health for All was adopted shortly after the elections on 3 November 2002, contains 11 dimensions of reform (Table 2).

On the basis of the Emergency Health Action Plan, the HTP was prepared in early 2003 under eight themes (Ministry of Health, 2010b):

1. the Ministry of Health as planner and supervisor2. universal and unified health insurance3. widespread, easy access to a friendly health care system characterized by: a) strengthened primary care and family medicine b) efficient and graduated referral chain c) health enterprises with administrative and financial autonomy4. highly motivated, knowledgeable and skilled human resources for health5. education and scientific institutions to support the system6. quality and accreditation for qualified and efficient health services7. corporate structuring in rational drug and supplies management8. access to effective knowledge in decision processes – health information system.

Additional details of the specific reforms are described elsewhere (e.g., Akdağ, 2012) and Annex 1 lists in chronological order the changes made under the HTP.

TABLE 2. EMERGENCY HEALTH ACTION PLAN: HEALTH FOR ALL

Strategies

1. Restructuring the Ministry of Health in administrative and functional terms.

2. Involving all citizens in the scope of universal health coverage.

3. Gathering health institutions under a single entity.

4. Making hospitals autonomous in financial and administrative terms.

5. Shifting to family medicine practice.

6. Putting special emphasis on mother and child health.

7. Disseminating preventive health.

8. Encouraging the private sector to invest in health.

9. Delegating authority to lower levels in all public institutions.

10. Overcoming the lack of health staff in priority regions for development.

11. Putting into practice the e-health transformation project.

Source: Ministry of Health, 2010b

5

As described in WHO (2012b), the reforms were carried out in a strategic way. Using a medical analogy, the Minister of Health and his team of advisers addressed the health system as a critically ill patient arriving in the emergency room with multiple life threatening traumas and illnesses. They first treated the life threatening conditions, then addressed the systemic (organ) problems and finally focused on cosmetic and quality-of-life issues.

But the strategic approach of the Minister and his team went considerably beyond the mere sequencing of reforms. In fact, they approached the reform of the health system in a manner that not only fits the definition of strategic planning, but also follows many of the steps typically involved with strategic planning. Before showing the role that strategic planning played in Turkey’s successful health reforms, it is useful to first define the term.

4. STRATEGIC PLANNING 4.1 BACKGROUND

The English term “strategy” is derived from the Greek word “strategos” which literally means “general of the army” and its use dates back (at least) to the battle of Marathon (490 BC) when a council of “strategoi” advised the political ruler about managing battles to win the war – and not on tactical advice about how to manage the troops to win battles (Blackerby, 2014).

With roots in this original meaning, strategy has been defined in modern times as “a plan of action designed to achieve a long-term or overall aim” (Oxford University Press, 2014) or “a careful plan or method for achieving a particular goal usually over a long period of time” (Merriam-Webster, 2014).

Myriad definitions of strategic planning also exist, e.g., “A systematic process of envisioning a future, and translating this vision into defined goals, objectives, strategies and tactics” (WebFinance, Inc., 2014) or “an organization‘s process of defining its strategy, or direction, and making decisions on allocating its resources to pursue this strategy” (Wikipedia, 2014).

These definitions show considerable overlap between the meaning of strategy and strategic planning, with the latter more broadly including the goals and objectives to be reached, as well as the strategies and decisions about allocation of resources to reach those goals. In the context of national strategic health plans, there is little agreement about the definition of terms like policies, strategies and plans, and the terms are frequently used interchangeably (WHO, 2010).

This report combines the two definitions above and defines strategic planning as: the process of envisioning a future and translating this vision into defined goals, objectives, strategies and tactics and making resource allocation decisions in pursuit of these objectives.

This definition implies a series of activities that form an integral part of strategic planning. Bryson (2011) describes 10 essential steps of strategic planning that he argues “should lead to action, results and evaluation”.


1. Initiate and agree upon a strategic planning process.2. Identify organizational mandates.3. Clarify organizational mission and values.4. Assess the organization’s external and internal environments to identify strengths, weaknesses, opportunities

and threats.5. Identify the strategic issues facing the organization.6. Formulate strategies to manage these issues.7. Review and adopt the strategic plan or plans.8. Establish an effective organizational vision.9. Develop an effective implementation process.10. Reassess strategies and the strategic planning process.

As discussed later, these steps closely match the strategic planning process in Turkey, but first a brief review of strategic planning in the public sector in Turkey.

4.2 A BRIEF HISTORY OF STRATEGIC PLANNING IN THE PUBLICSECTOR IN TURKEY

While public sector planning in Turkey goes back to the 1940s (Gorun & Emini, 2011), strategic planning took hold at a much later date. In fact, it was only when the58th Government came into office in 2002 that legislation was passed in 2003 mandating strategic planning in the public sector. Article 9 of Public Law No. 5018 on Public Financial Administration and Control (Republic of Turkey, 2012) states:

Public administrations shall prepare strategic plans in a cooperative manner in order to form missions and visions for [the] future within the framework of development plans, programs, relevant legislation and basic principles adopted; to determine strategic goals and measurable objectives; to measure their performance according to predetermined indicators and to monitor and evaluate this overall process.

The law further declares that in “order to present public services at the required level and quality, public administrations shall base their budgets and their program and project-based resource allocations on their strategic plans, annual goals and objectives and performance indicators” (Republic of Turkey, 2012).

On the surface, these mandates seem relatively innocuous; however, in practice they posed a major challenge to a bureaucracy unfamiliar with the concepts of strategic planning and performance-based budgeting. This challenge was exacerbated by the failure of Public Law No. 5018 to specify who would be responsible for the development of the strategic plans and the performance-based budgets. It is therefore not surprising that not much happened until it was amended in 2005 by Public Law No. 5436 to establish organizational entities – the so-called Strategic Development Presidency in all Ministries (and strategic planning departments in public administrations) – that were mandated to:

determine medium and long-term strategy and policies; develop performance and quality indicators; collect, analyse and comment on information; examine external factors, study intra-institutional capacity, analyse effectiveness of services and satisfaction level; and carry out services related to management information systems.

7

This legislative change was accompanied by regulations – The Regulation on Principles and Procedures for Strategic Planning in Public Administration – issued by the State Planning Organization to help ensure that the law was implemented. They also issued a Strategic Planning Guide to provide guidance on how to develop the strategic plans (European Commission, 2009; Gorun & Emini, 2011). According to these documents, strategic planning in Turkey:

must be based on wide consultation with internal and external stakeholder participation and their input be considered and included;

should be performed with the participation of all units under the coordination of the strategic development unit within each ministry;

must be done by the public administrations themselves (only limited consultancies were allowed); and should include all relevant public administrations who should work in harmony, cooperation and coordination.

With this legislative amendment and the accompanying regulations and planning manual, implementation of the strategic planning mandate began. During a pilot phase, eight institutions were selected to prepare strategic plans that were completed in 2006. The Ministry of Health was not among the pilot institutions, although the Directorate General of Health for Border and Coastal Areas was included (Gorun & Emini, 2011). The pilot plans were prepared in collaboration with the Undersecretariat of the State Planning Organization and with the oversight of the Ministry of Finance. The second implementation phase took place between 2006 and 2009, when a large number of public administrations set out to prepare their own strategic plans, which were reviewed by the Undersecretariat of the State Planning Organization. By October 2010, 140 strategic plans had been reviewed, and 121 revised and finalized (Gorun & Emini, 2011), including the Ministry of Health’s Strategic Plan 2010–2014 (Ministry of Health, 2010b).

5. STRUCTURE AND CONTENT OF TURKEY’SSTRATEGIC PLANS FOR HEALTH Reflecting the importance attached by the Government to strategic management, of which strategic planning is an important component, the national strategic plan for health is divided into five sections: strategic analysis, strategic design, relevance of strategic plan with high-level policy documents, strategic implementation, and the monitoring and evaluation (M&E) process.

Part 1: Strategic Analysis contains: 1.1 History 1.2 Regulations 1.3 Strategic Planning Process 1.4 Organizational Structure 1.5 Resources 1.6 Stakeholder Analysis 1.7 Strengths, Weaknesses, Opportunities, and Threats (SWOT) Analysis 1.8 Strategic Issues


Part 2: Strategic Design contains the mission, vision and values statements, as well as the strategic issues, the overall goal, strategic objectives and target-oriented strategies: 2.1 Mission 2.2 Vision 2.3 Basic Principles and Values 2.4 Strategic Map 2.5 Strategic Purposes 2.6 Strategic Targets and Target-oriented Strategies

To ensure that the strategic plan is consistent with higher-level policy documents, Part 3 contains a number of policy matrices mapping the strategic objectives to relevant high-level policy documents.

Part 4: Strategic Implementation is devoted to the specifics related to the implementation of the strategic plan: 4.1 Performance Targets, Performance Indicators 4.2 Target/Unit in Charge Matrix 4.3 Strategic Plan Budget

The last section – Part 5 – describes the M&E process, including reports to be prepared and by whom.

Both the first and the second strategic plan for the health sector followed the above format with only minor deviations.2 How the content changed from one to the other is the subject of the next section.

6. EVOLUTION OF STRATEGIC PLANNING FORHEALTH IN TURKEY The first national strategic plan, Strategic Plan 2010–2014 (SP1), and the second plan, Strategic Plan 2013–2017 (SP2), overlap, or put differently, SP2 began before the originally foreseen end of SP1. The main reason for the overlap was that with the issuance of Statutory Decree No. 663, the Ministry of Health would be reorganized and its role and responsibilities would change significantly (Republic of Turkey, 2011; Akdağ, 2012), thereby fulfilling one of the important strategic objectives (SO 2.3) of SP1. In general terms, it would go from being a key provider of health services to being the steward of the health sector. It would therefore be necessary to develop a second strategic plan to reflect these changes. A secondary reason was that many of the strategic objectives and associated targets set in SP1 had already been achieved by 2012; so new objectives and targets were needed. Finally, the adoption of the new European policy framework – Health 2020 – at the 62nd session of the Regional Committee for Europe in Malta in 2012, with new strategic orientations and priority areas for action,3 also necessitated a revision in Turkey’s strategic plan (WHO Regional Office for Europe, 2012d).

2 In the second strategic plan (2013–2017), Part 1 included sections on Strategic Management (1.3) and Situation Analysis (1.7) that were not included in the first plan. Similarly, the first strategic plan (2010–2014) includes a section on Strategic Purposes (2.5) that was dropped from the second plan.

3 Health 2020 aims to “significantly improve the health and well-being of populations, reduce health inequalities, strengthen public health and ensure people-cen-tred health systems that are universal, equitable, sustainable and of high quality” and emphasizes the need for action across government and society. The policy framework identifies four priority action areas: (1) investing in health through a life-course approach and empowering people; (2) tackling Europe’s major health challenges of noncommunicable and communicable diseases; (3) strengthening people-centred health systems, public health capacity and emergency prepared-ness, surveillance and response; and (4) creating resilient communities and supportive environments (WHO Regional Office for Europe, 2013).

9

When analysing the evolution of strategic planning in Turkey, it is necessary to explore all the key components of the plans. To this end, Table 3 lists the key dimensions (mission, vision, goals, etc.) of SP1 and SP2 side by side. But this table would be incomplete without information about the HTP from 2003–2009, because even in the absence of an official strategic plan prior to 2010, several arguments support the notion that strategic planning played an important role in the success of this programme.

First, based purely on inductive reasoning, it would seem highly unlikely that after many years of stagnation in the health sector, Turkey would experience improvements of such magnitude over a relatively short period of time without a concerted effort and some sort of strategic plan. Second, there was an Emergency Action Plan (Section 3), which contained a number of objectives that would qualify as strategic objectives, particularly since they were based on previous years’ analyses (Ministry of Health, 2012a). Third, the HTP process closely resembles the 10 steps in Bryson’s strategic planning model (Annex 2) (Bryson, 2011). Fourth and perhaps most importantly, Public Law No. 5018, which mandates all public administrations to prepare strategic plans, provides clear evidence of the importance attached to strategic planning by the Government of Turkey. It therefore seems justified to conclude that even in the absence of an official strategic plan, strategic planning played an important role in the success of the HTP (2003–2009) and the dramatic improvement in health and health system outcomes.

To complete the analysis of the evolution of strategic planning in Turkey, Table 3 contains a column with information about the HTP, referring to it as Strategic Plan zero (SP0). The content related to SP0 was developed on the basis of information contained in various progress reports and evaluation documents covering the period 2003–2009 (e.g., Ministry of Health, 2010a; Akdağ, 2012). Sometimes the information was readily available in these documents; in other cases it was inferred from what was written. While this approach is necessarily somewhat inexact, it does allow one to observe the changes that took place from SP0 to SP1 and SP2.

7. ANALYSIS OF THE EVOLUTION OF STRATEGICPLANNING FOR HEALTH IN TURKEY Analysis of the content in Table 3 yields many insights into the evolution of strategic planning since the early days of the HTP. This section focuses on the main themes.

First, the length of the strategic planning process has evolved from being very short (SP0) to much longer, with the preparation of SP1 taking longer than SP2. It has also become much more inclusive. SP0 basically just involved the Minister of Health and his small team of advisors. In contrast, the preparation of both SP1 and SP2 included extensive consultations with input from internal, as well as external stakeholders, as mandated by The Regulation on Principles and Procedures for Strategic Planning in Public Administration (European Commission, 2009; Gorun & Emini, 2011). While the consultations for SP1 appeared to be mostly pro forma with little noticeable impact on the formulation of the strategic goals, strategic objectives or targets, the consultations for SP2 led to modifications in the final plan. Not only were the formulation of the strategic goals and objectives modified (Ministry of Health, unpublished data, 2012), but each organizational unit responsible for some aspect of the implementation of the plan played an active role in the


development of the activities to be carried out, as well as the M&E indicators to measure progress on the achievement of the objectives and subobjectives. As a result, SP2 is likely to enjoy much wider ownership among stakeholders.

Item HTPa SP1b SP2c

Process This initial plan was developed very quickly mainly with input from members of the Minister’s team of advisors. Subsequent changes and implementation typically involved much greater stakeholder involvement. Without a formal strategic plan, there could be no formal dissemination, but the Minister and his team of advisors made a large number of site visits to disseminate information about the HTP as part of the implementation process, as did the implementation teams (Ministry of Health, 2010a; WHO Regional Office for Europe, 2012b).

The process was relatively lengthy, in part because it was prescribed by regulations to include extensive stakeholder consultations. However, the description of the feedback received (p. 34) suggests that it mostly concerned satisfaction ratings regarding how the Ministry performed or the degree to which it was open to change and collaboration. It is therefore unclear whether the stakeholder consultations actually yielded any feedback that could, or did, lead to substantive changes in the strategic goals, objectives or targets to be achieved. Rather the description of the stakeholder analysis gives the impression of having been done to fulfil a regulatory decree as opposed to building true ownership of the plan, which is one of the main reasons for doing such consultations.

This plan was prepared under a considerable amount of time pressure in order meet the end of the year deadline (in 2012) imposed by the State Planning Organization. However, the mandated stakeholder consultations took place with inputs that were incorporated into the final plan (Ministry of Health, unpublished data, 2012).

Situation analysis

As noted above, a diagnostic exercise to identify the root causes of the performance problems was carried out in place of a regular SWOT analysis.

Besides a SWOT analysis, no formal situation analysis performed was performed.

There was a SWOT analysis, as well as a description of the achievements under the HTP since 2002, but no diagnostic analysis.

Mission To organize, finance and deliver health services in an effective, efficient and equal fashion (Ministry of Health, 2010a)

To protect and improve the health of our citizens.

To maximize the protection of individual and community health with a people-centred approach and to offer timely, appropriate and effective solutions to health problems.

Vision A Turkey in which all citizens, as people of the country with equal rights, enjoy access to health services on an equitable basis. (Ministry of Health, 2010a)

A Turkey in which everyone lives in health and prosperity.

A Turkey where healthy lifestyles are embraced and everyone can easily exercise their right to health.

Principles and values

- People-centredness - Sustainability - Continuous quality - (Equity as strategic objective) - Participation - Reconciliation - Volunteerism - Separation of powers - Decentralization - Competitiveness in service

- People-centred - Quality - Equity - Being scientific - Ethics - Teamwork - Being environmental-friendly - Guidance

- People-centred - Universality - Equity - Participation - Solidarity - Reputability - Work ethics - Transparency - Accountability - Sustainability - Evidence-based - Quality and efficiency - Innovation in health

TABLE 3. EVOLUTION OF STRATEGIC PLANNING FROM HTP TO SP1 TO SP2

11

Item HTPa SP1b SP2c

Ultimate goal

To increase the level of health care and therefore the welfare and happiness level of the society (Ministry of Health, 2010b; p. 235).

To increase and improve the health status of people

To protect and improve the health of our people in an equitable manner

Strategic goals

1. Restructuring the Ministry of Health in administrative and functional terms

2. Involving all citizens in the scope of universal health coverage.

3. Gathering health institutions under a single entity

4. Making hospitals autonomous in financial and administrative terms

5. Shifting to family medicine practice

6. Putting special emphasis on mother and child health

7. Disseminating preventive health8. Encouraging the private sector to

invest in health9. Delegating authority to lower

levels in all public institutions10. Overcoming the lack of health

staff in priority regions for development

11. Putting into practice the e-health transformation project

1. To protect society from health risks

2. To ensure provision of required health services in a quality and safe way

3. To supervise equity, to ensure responsiveness while focusing on people oriented approach in health-care services

1. To protect the individual and the community from health risks and foster healthy life styles

2. To provide accessible, appropriate, effective and efficient health services to individuals and the community

3. To respond to the health needs and expectations of individuals based on a people-centred and holistic approach

4. To continue to develop the health system as a means to contributing to the economic and social development of Turkey and to global health

Strategicobjectives

These were called themes and formulated in a way that includes a mixture of vision and strategic objectives (pp. 20–21):

1. The Ministry of Health as planner and supervisor

2. Universal and unified health insurance

3. Widespread, easy access to a friendly health care system characterized by: - strengthened primary care and family medicine - efficient and graduated referral chain - health enterprises with administrative and financial autonomy

4. Highly motivated, knowledgeable and skilled human resources for health

5. Education and scientific institutions to support the system

6. Quality and accreditation for qualified and efficient health services

7. Corporate structuring in rational drug and supplies management

1.1 To ensure all people get access to health promotion and healthy living programmes

1.2 To improve maternal, child and adolescent health and to reduce the maternal mortality rate to no more than 10 per 100 000 live births, and the infant mortality rate to no more than 10 per 1 000 live births by the end of 2012

1.3 To continue improving emergency health care services and disaster health management so it operates in a timely, effective and efficient manner

1.4 To reduce the prevalence of and deaths from communicable diseases

1.5 To reduce the prevalence of and deaths from noncommunicable diseases

1.6 To increase to more than 80% the rate of non-smokers above the age of 15 by the end of 2014, to implement the alcohol control programme and to reduce addictive substance use

1.1 To develop healthy dietary habits, increase the level of physical activity and reduce obesity

1.2 To sustain the fight against tobacco use and to reduce the exposure to tobacco and the use of addictive substances

1.3 To develop health literacy to increase individuals’ responsibility for their health

1.4 To raise awareness of reproductive health and encourage healthy behaviours

1.5 To reduce the negative impact on health of public health emergencies and disasters

1.6 To protect and promote the health and well-being of employees by improving occupational health

1.7 To mitigate the negative impact on health of environmental hazards

1.8 To carry out effective actions on social determinants of health by mainstreaming health in all policies

1.9 To combat and monitor commu-nicable diseases and risk factors


Item HTPa SP1b SP2c

Strategicobjectives (continued)

8. Access to effective knowledge in decision processes – health information system.

1.7 To increase the proportion of the population living in a healthy and safe physical environment

1.8 To ensure access of all employees to occupational health services, and to reduce the levels of mortality and disability due to occupational diseases

2.1 To continue improving hospital services in administrative, structural and functional ways, and to increase the service standards and efficiency

2.2 To increase the quality of diagnosis, curative and rehabilitation services, and to ensure the provision of these services within principles of accessibility, efficacy, efficiency, measurability and equity

2.3 To clarify the stewardship, regulatory, planning and supervisory role of the Ministry of Health by the end of 2011 in light of its planned restructuring

2.4 To complete the organization of community and region-based health services by the end of 2014 and to make the regions self-sufficient health zones

2.5 To support research and development for scientific publications that improve health care services

2.6 To improve pharmaceuticals and medical device services and to sustain safe, accessible and quality provision

2.7 To complete, operate and improve Turkey’s Health Information System/e-health, which will ensure access to effective information for decision-making and service provision

2.8 To make sectors accountable for the impact of their policies and actions on health, and to improve multisector health accountability policy

2.9 To continue cooperation with other nations and international organizations in the area of health, to make Turkey a regional centre of expertise and to increase its capacity to provide transborder health services

1.10 To reduce and monitor the incidence of noncommunicable diseases and risk factors

2.1 To improve the quality and safety of health services

2.2 To protect and improve maternal, child and adolescent health

2.3 To ensure the effective utilization of preventive and essential health services

2.4 To sustain appropriate and timely access to emergency care services

2.5 To improve the integration and continuity of care by strengthening the role of primary health care

2.6 To control and reduce the complications of noncommunicable diseases

2.7 To strengthen the regulations of traditional, complementary and alternative medical practices to ensure their effectiveness and safety

2.8 To continue to improve the distribution, competences and motivation of human resources for health, and to ensure the sustainability of human resources for health

2.9 To improve the quick capacity, quality and distribution of the health infrastructure and technologies and to ensure their sustainability

2.10 To ensure accessibility, safety, efficacy and rational use of drugs, biological products and medical devices, and the safety of cosmetic products

2.11 To enhance the health information systems for monitoring and evaluation of, and evidence-based decision-making for, the health service delivery system

3.1 To strengthen the role of individuals in order to ensure their active participation in decisions regarding their health care

3.2 To better meet the needs of individuals with special needs due to their physical, mental, social or economic conditions by ensuring easier access to appropriate health services

13

Item HTPa SP1b SP2c

Strategicobjectives (continued)

3.1 Taking a people oriented approach as the basis for health care service provision to prioritize people in need due to physical, mental, social or economic conditions

3.2 To disseminate family medicine practice nationwide by the end of 2010 in order to increase the quality of and provider and patient satisfaction rate from primary level health care services and to generate people-oriented service

3.3 To respond to the expectations of patients and relatives, as well as medical necessities during health service processes, to increase the level of satisfaction

3.4 To protect people from financial risks when accessing health services

3.3 To contribute to ensuring equity in the financing of health services and protection of individuals from financial risks

3.4 To increase the satisfaction of individuals with their health services and that of health workers with their working conditions

4.1 To maintain a financial sustainability of the health care system without compromising service quality through implementation of evidence-based policies

4.2 To monitor health system performance and to document its contribution to health and the national economy

4.3 To promote research, development and innovation in priority fields of the health sector

4.4 To promote the contribution of the health sector to the economy

4.5 To strengthen health tourism in Turkey

4.6 To be among the leaders in the development and implementation of global regional health policies

4.7 To contribute to global health through cooperation and development aid

Targets and indicators

In the absence of a formal plan, it is not possible to identify if specific targets and indicators were part of SP0. However, the progress shown by the Ministry of Health (2010a) provides ample evidence that there were specific objectives to be achieved. Furthermore, the comparisons contained in that document give the impression that Turkey was keen to exceed at least the averages in the WHO European Region.

SP1 contains a large number of targets and indicators (252) that was used to monitor progress on implementation. Given that many of the objectives to be achieved concerned changes in, for example, the legal framework, many of the indicators where qualitative in nature. Not all indicators specified a target date for completion.

Like SP1, SP2 contains a large number of indicators; however, the number was reduced from 254 to 117. Furthermore, all indicators have targets to be achieved by specified dates (2017 and 2023). The quality of the indicators have increased and become more outcome focused than previously. Strengthening the health information systems is among the objectives to ensure that information is available on all targets.

M&E frame-work

As discussed above, the M&E framework was a critical element of this plan’s success.

This section lists the activity results that Senior Management would de ve - lop on an annual basis (pp. 120–123).

The M&E framework is further developed and now utilizes the framework development M&E.

Higher-level policy frame-works

Consistent with both the 9th Development Plan for Turkey (T.R. Prime Ministry & State Planning Organization, 2007) and the Health21 policy framework (WHO Regional Office for Europe, 1998)

Part 3 contained three tables documenting relations between the strategic health plan and higher-level policy documents: - Table 10. Relation between targets

of the 9th Development Plan (T.R. Prime Ministry & State Planning Organization, 2007) and objectives of SP1;

Part 3 contains five tables documenting relations between the strategic health plan and higher-level policy documents: - Table 6. Links between the

objectives of the 9th Development Plan (T.R. Prime Ministry & State Planning Organization, 2007) and SP2;


Item HTPa SP1b SP2c

Higher-level policy frame-works (continued)

- Table 11. Relation between targets of the 60th Government Programme and objectives of SP1; and

- Table 12. Relation between Health21 (WHO Regional Office for Europe, 1998) and the objectives of SP1.

- Table 7. Links between the Tallinn Charter: Health Systems for Health and Wealth and objectives of SP2 (WHO Regional Office for Europe, 2008);

- Table 8. Links between Health 2020 and policy priorities and the objectives of SP2 (WHO Regional Office for Europe, 2013);

- Table 9. Links between the European Action Plan for Strengthening Public Health Capacities and Services (WHO Regional Office for Europe, 2012a) and the objectives of SP2; and

- Table 10. Links between the WHO Global Strategy on People-centred and Integrated Health Services (WHO, 2014b) and SP2.

a Information comes from Akdag (2011) and the Ministry of Health (2010a).

b The page numbers in this column refer to the Ministry of Health (2010b).

c The section references in this column refer to the Ministry of Health (2012a).

Second, the situation analysis that underpinned the HTP was a detailed, diagnostic exercise that clarified the underlying root causes of the myriad performance problems in the Turkish health system in 2002. In contrast, the situation analysis contained in SP1 was a traditional SWOT analysis that focused on organizational weaknesses, as opposed to identifying the root causes of the performance problems. Given that both SP1 and SP2 were continuations of SP0 (the HTP) and the latter did identify the root causes of the problems, there may not have been a need to re-do the root-cause analysis. However, at some point in the future, repeating the root cause analysis will be necessary, which means that the current regulation mandating the use of a SWOT analysis is likely to be insufficient to identify all the reforms or initiatives that will be needed to address future performance problems; an issue of which the senior management of the Ministry of Health is well aware.

Third, the mission and vision statements have changed in subtle but important ways. While SP0 focused on equal rights and access to health service, SP1 focuses on improving health outcomes and living in health and prosperity. In contrast, SP2 focuses on lifestyles, protection and appropriate solutions to health problems. Note that in the latter case, the solutions might lie outside the health sector, reflecting the importance of the whole-of-society and whole-of-government approaches embraced in Health 2020 (WHO Regional Office for Europe, 2013). A similar evolution can also be observed about the formulation of the ultimate goal (Table 3).

Fourth, even though the principles and values vary across the different periods, there is a considerable amount of consistency. People-centredness is a core value across all three plans, which is to be expected since this value had been a core value of the Government since it first took power in 2002. Similarly, quality or continuous quality improvement has also been a core value throughout all three periods. Again, this is hardly surprising, given that good quality care is essential to achieve both good health and patient satisfaction, two key objectives of the health sector and the Government of Turkey. Similarly, equity is a consistent value, reflecting both the importance attached by the Government to serving people in rural areas and the impact of Health 2020, which highlights the importance of equity (WHO Regional Office for Europe, 2013).

15

Other values or principles appear with less regularity, some only once. Sustainability is a priority in SP0 and SP2, but not in SP1; “being scientific” becomes an express principle in SP1 and continued in SP2 albeit now expressed as “evidence-based”, a term more commonly used in the literature. Curiously, that term is not among the expressed values and principles in SP0, even though the strategies developed for the HTP were clearly evidence-informed (Akdağ, 2012). Finally, it is interesting to note the presence of values such as “transparency” and “accountability” in SP2, which probably reflect both the impact of Health 2020 and the emerging importance of these concepts in the literature on public administration and international development (see, for example, Armstrong, 2005; and Wenar, 2006).

Fifth, the strategic goals become more focused and concise, as well as increasingly sophisticated over time. Since there was no formal strategic plan for the HTP and the items included in the 2002 Emergency Action Plan are more strategies than goals (with the exception of the emphasis placed on maternal and child health), this discussion refers only to the change from SP1 to SP2. Probably reflecting the above-mentioned change in values and principles, the strategic goals evolve from “to protect the society from health risks” in SP1 to “protect the individual and the community from health risks and foster healthy life styles”. Similarly, in SP2 “ensuring quality and safe health services” become providing “accessible, appropriate, effective and efficient health services”. Strategic goal 3 in SP1, which includes quite different concepts (e.g., supervise equity, ensure responsiveness), turns into two strategic goals that more accurately reflect the true goals (as evidenced by the strategic objectives). Another noteworthy aspect of the evolution of the strategic goals is that they move from being mostly focused on health or health system-related issues to also include much broader goals, such as “to develop the health system as a means to contributing to the economic and social development of Turkey and to global health” (Ministry of Health, 2012a).

Sixth, since there are too many strategic objectives to discuss in detail, suffice it here to observe a few particularly noteworthy trends. The strategic objectives in SP0 all focus on needed health system strengthening efforts or reforms. While SP1 still includes several comprehensive reforms that needed to be implemented (e.g., clarifying the stewardship role of the Ministry of Health and completing the organization of community- and region-based care), SP1 includes a number of more outcome-oriented objectives, such as reducing the prevalence of, and mortality due to, both communicable and noncommunicable diseases; ensuring financial risk protection and holding other sectors accountable for their health impact. International cooperation and transborder services also enter the list of strategic objectives.

SP2 continues the trend away from reforms, which have mostly been completed, toward strategic objectives that emphasize outcome-oriented strategic objectives, in the process expanding both their numbers and scope. Protection against environmental hazards becomes a strategic goal, as does occupational health. Taking responsibility for one’s own health and actively participating in health care decisions are also included, as is addressing social determinants of health. In the area of health services, focus is expanded to include integration and continuity of care, as well as regulation of traditional, complementary and alternative medical practices. Maintaining financial sustainability becomes an explicit objective for the first time, as does measuring and strengthening the health sector’s contribution to the economy. Finally, becoming a leader in the development of global and regional health policies and contributing to global health are added to the list of new priorities.

These trends clearly show that the focus was first on fixing the root causes of the so-called broken health system, then on adding and expanding the focus to other related areas within the health sector, followed by other sectors and finally the outside world. An approach exactly resembling the way in which a team of medical doctors would tackle the treatment of a critically ill patient arriving in the emergency room with multiple life-threatening traumas and illnesses,


which was the medical analogy used by the Minister and his team to guide their approach to the HTP in general (WHO Regional Office for Europe, 2012b).

Seventh, like the strategic objectives, the indicators associated with these objectives also become more concise. Where there were 254 indicators for SP1, there are only 117 for SP2. Furthermore, many of the indicators in SP1 focused on structure or process measures (e.g., number of qualified beds, number of physicians per 1000 population, rate of electronic health card use, sample flowcharts and diagnosis algorithms published). The indicators for SP2 are much more outcome-focused,4 particularly, as related to clinical outcomes of noncommunicable disease patients (e.g., metabolic control in diabetic patients, complications rates, cholesterol levels, etc.).

Similarly, quality and safety indicators include surgical wound infection rates, in-hospital fatality rates within 30 days of admission for acute myocardial infarction, unplanned re-admission rate to hospitals for the same condition within 7 days of discharge, incidence of nosocomial infection rate, etc. While data for many of these indicators did not exist at the time that SP2 was prepared, their collection is part of the further development of the information systems that is an objective that continues to enjoy high priority (objective 2.11). Few, if any, other countries regardless of income level have national strategic plans that monitor the kind of outcome-oriented indicators contained in SP2. In fact, a recent study of diabetes programs in five western European countries (France, Germany, Italy, Spain and the United Kingdom) found that national monitoring systems were weak, characterized by a dearth of outcome-oriented indicators at the national level, with only the United Kingdom regularly monitoring outcomes like glycosylated haemoglobin (HbA1c) levels (Kanavos et al., 2012).

Eighth, the utility of having a dedicated section devoted to identifying how the strategic plan maps to other high-level policy frameworks becomes clear when one inspects the changing frameworks from SP0 to SP1 and SP2. Without a dedicated section, it would be easy to forget to ensure that the plan reflected new developments on both the domestic and the international front. Note in particular, the documented impact on, for example, the values and principles, of the change from Health21 to Health 2020 (WHO Regional Office for Europe, 1998; 2013).

The impact of Health 2020 is also evident in the increasing importance of intersectoral actions, which play no role in SP0, but are prominent in both SP1 (cf. SO 2.8) and SP2 (cf. SO 1.8). To achieve these objectives, the Ministry of Health initiated a process in 2011 that led to the approval, in 2013, of a Program for Improving Multisectoral Health Responsibility 2013–2023. This programme was prepared with input from all public institutions, as well as more than 600 experts from academia and the private sector and is a significant tool for ensuring multisectoral responsibility and accountability for health (Ministry of Health, 2013b). It is also intended to ensure that “preventive health care services will be developed with a multisectoral approach that takes individual, social, biological and physical environmental factors into account to ensure that individuals are at a complete wellness state in body and mind” as required by Turkey’s Tenth Development Plan 2014–2018 (cited in Ministry of Health, 2013b), adopted on 2 July 2013 by the Grand National Assembly of Turkey (Çağlar & Acar, 2013).

Ninth, the evolution of the M&E framework reflects the increasing formalization and institutionalization of the HTP reforms. As described by the WHO Regional Office for Europe (2012b), one of the important determinants of the HTP’s success was the M&E system, particularly the informal channels that allowed information to flow directly from the front lines to the Minister and his team, who then could take quick action on any problems that were identified.

4 Examples of specific outcome-oriented indicators include, but are not limited to, the percentage of diabetic patients good long-term control of their diabetes, as measured by glycosylated haemoglobin (HbA1c) ≤ 7% (MedlinePlus, 2014); the percentage of hypertensive patients with retinopathy caused by high blood pressure; and the percentage of people with total cholesterol level ≥ 200 mg/dL.

17

While this system worked very well, it was not fully developed, nor institutionalized by the time SP1 was prepared. SP1 therefore provides the first step towards the development of a formal M&E system, which with the reorganization of the Ministry of Health and the establishment of the Health Policy Board in 2011 becomes fully institutionalized, as described in SP2.

Tenth, the increasing institutionalization goes beyond the M&E framework and reflects an increasing institutionalization of the HTP reforms, in particular the concepts of strategic planning and strategic management. As argued above, strategic planning and strategic management were clearly important tools for the Minister and his team from the very beginning, but even after SP1 was published, its use was limited to the senior management. The SP2 continues to serve the senior leadership as a management tool but also becomes a tool for ensuring continuity of the HTP reforms, when a new Minister of Health, Dr Mehmet Müezzinoğlu takes office on 24 January 2013 (Ministry of Health, 2014), replacing Professor Recep Akdağ, who had led the HTP since its inception.

In contrast to SP1, the dissemination of SP2 has been wider. It was, for example, presented to and discussed in the Turkish National Grand Assembly (TNGA) by Dr Müezzinoğlu on 20 November 2013, which not only would have increased its members’ knowledge of the plan, but (hopefully) also their understanding of and support for needed reforms and other initiatives.

The publication of the formal strategic plan was also accompanied by publication of a pocket-sized, abridged version of SP2, distributed to all relevant staff throughout the Ministry of Health (and other relevant public agencies). Not only has the abridged version of SP2 been widely disseminated, but departmental units were asked to prepare annual work plans reflecting how they will achieve the objectives relevant to their work. Progress on these work plans are monitored on a quarterly basis while progress on the target indicators is measured on an annual basis. Furthermore, request for additional resources from these units have to be accompanied by justification tied to one or more strategic objectives. This sort of use is exactly what is envisaged in Strategic Management models and what increases the likelihood that the plan will succeed, since “what gets measured, gets done” (P. Drucker quoted in Lucid & Lepidi, 2011) as the saying goes in management circles.

8. STRATEGIC PLANNING AND HEALTH SYSTEMPERFORMANCE IN TURKEY Section 2 documented the improvements in health systems performance that the HTP brought about, while Sections 5 and 6, respectively, described and analysed the evolution of strategic planning for health in Turkey. This section identifies what factors made Turkey’s strategic planning successful.

Obviously, many factors contributed to the success of strategic planning in Turkey, but three were particularly significant. First, Turkey’s national strategic health plans avoided three common pitfalls that undermine the realizations of many such plans (Andersen, 2013): the plans were not a wish list, contained goals that were both realistic and achievable, and were not externally imposed, thus ownership was not a problem.


Second, Turkey’s strategic plans were an integral part of a strategic management system that also included strategic implementation and strategic control. Furthermore, great attention was paid to the implementation of all the components of this system. As a result, the plans turned into actionable items.

Third, Turkey’s plans (from the HTP through SP2) come close to the so-called sound standard, as developed by the International Health Partnership (IHP+) and related initiatives (WHO, 2014a). Since this report focuses on strategic plans, the remainder of this section is devoted to providing a description of this sound standard and then to assessing Turkey’s strategic plans according to its attributes.

8.1 A SOUND STANDARD FOR NATIONAL STRATEGIC HEALTH PLANS

No formally approved international standards for national strategic health plans exists, but IHP+ has developed a joint assessment tool that defines the attributes of a sound national strategy (IHP+, 2011). This tool is used in this report as a sound standard.

IHP+ is a partnership of international organizations, bilateral donors, civil society and developing countries working to put into practice international principles for effective aid and development cooperation in the health sector. It was launched in 2007 by 26 partners – that number has since more than doubled – to accelerate progress on the health Millennium Development Goals and as a means to operationalize the Paris Declaration on Aid Effectiveness and the Accra Agenda for Action (Organisation for Economic Co-operation and Development, 2005). The work of IHP+ revolves around the development, approval and monitoring of country-level national health strategies and plans (NHSP),5 which form the basis for country compacts to which all the IHP+ partners commit themselves.

An important part of the preparation of a country compact is a joint assessment of the country’s national health strategy and the associated common results monitoring framework.6 To this end, an interagency working group established by IHP+ developed an assessment tool with guidelines. The tool was reviewed by seven countries and tested by international organizations, including but not limited to WHO and the World Bank, before IHP+ partners in 2009 endorsed it. Since then the tool has been updated in response to lessons learnt in the countries that have used it (please see IHP+ (2012)).

The Joint Assessment of NHSP (JANS) was developed to assist IHP+ countries and their development partners in the development of “sound, relevant and achievable” NHSP (WHO, 2014a). Specifically, JANS is intended to be used in one of two ways: during the development of a national strategy as a guide for the process and the content development, or near the completion of the strategy as a review mechanism, which is not how it was used in this report. Furthermore, given that IHP+ was developed specifically for low-income countries with a high level of donor engagement and funding, the JANS tool contains a few criteria that are relevant only for such countries. However, since the tool in this report is used predominantly as a pedagogical tool to understand why Turkey’s strategic health plans have been so successful, this does not pose a problem. These criteria are simply ignored.

The joint assessment tool focuses on five aspects that any sound national strategy should contain. And though not specifically prescriptive, it contains 16 attributes that would describe a sound strategic plan. Each attribute is associated

5 In the context of IHP+, the terms national health strategies and plans are used interchangeably.6 The joint assessment is usually carried out by a JANS Core Group of five or six members, including members of the Ministry of Health, development partners and

civil society who report back to the Health Sector Coordination Committee (WHO, 2014a; p. 6).

19

with a number of criteria describing the characteristics of that attribute. The purpose of the attributes and the criteria is to identify strength and weaknesses of the country’s strategic plan to which it is applied (IHP+, 2011). Table 4 describes the 16 attributes that make up the JANS tool. In order to save space, the assessment criteria associated with each attribute is in Annex 3.

Aspect Attribute Characteristics of the attribute

1. Situational analysis and programming

1 National strategies are based on a sound situation and response analysis of the context (including political, social, cultural, gender, epidemiological, legal, governance and institutional issues).

2 The national strategy sets out clear priorities, goals, policies, objectives, interventions and expected results that contribute to improving health outcomes in equity, and to meeting national and global commitments.

3 Planned interventions are feasible, locally appropriate, equitable and based on evidence and good practice, including consideration of effectiveness, efficiency and sustainability.

4 An assessment of risks and proposed mitigation strategies are present and credible.

2. The process 5 Multistakeholder involvement in the development of the national strategy and operational plans and multistakeholder endorsement of the final national strategy are in place.

6 They are indications of a high level of political commitment to the national strategy.

7 The national strategy is consistent with relevant higher and/or lower level strategies, financing frameworks and plans.

3. Costs and financing of the strategy

8 The national strategy has an expenditure framework that includes a comprehensive budget/costing of the programme areas covered by the national strategy.

9 The strategy has a realistic financing framework and funding projections. If the strategy is not fully financed, there are mechanisms to ensure prioritization in line with overall objectives of the plan.

4. Implementation and management

10 Operational plans are regularly developed through a participatory process and detail how national strategic objectives will be achieved.

11 The national strategy describes how resources will be deployed to achieve outcomes and improve equity, including how resources will be allocated to subnational level and non-state actors.

12 The adequacy of existing institutional capacity to implement the strategy has been assessed and their plans to develop the capacity required.

13 Financial management and procurement arrangements are appropriate, compliant and accountable. Action plans to improve public financial management and procurement address weaknesses identified in the strategy and another diagnostic work.

14 Governance, accountability, management and coordination mechanisms for implementation are specified.

5. Monitoring, evaluation and review

15 The plan for M&E is sound, reflects the strategy and includes core indicators; sources of information; methods and responsibilities for data collection, management, analysis and quality assurance.

16 There is a plan for joint periodic performance reviews and processes to feedback the findings into decision-making and action.

TABLE 4. JAN ATTRIBUTES

Source: adapted with permission from IHP+ (2011).


8.2 ASSESSMENT OF TURKEY’S STRATEGIC PLANS Table A3.1 in Annex 3 lists the JANS attributes and associated criteria. This table also describes each criterion applied to Turkey’s strategic plans (SP0, SP1 and SP2). In absence of an official strategic plan for the HTP 2003–2009 (i.e., SP0), the content for SP0 was derived from information in available documents (e.g., progress and evaluation reports about the HTP such as from the Ministry of Health, 2010a) pertaining specifically to this time period. Since the objective here is not to assess SP0, which does not exist, but rather to analyse the evolution of strategic planning in Turkey, this method with its obvious limitations serves that purpose reasonable well. The few exceptions are noted in Table A3.1 or the analysis below.

Since Table A3.1 is long and contains myriad details that are not important for the overall conclusions that may be drawn from it, only the main points are presented.

The first impression is how closely Turkey’s strategic plans come to fulfilling the attributes described in JANS and developed to ensure health strategies that are “sound, relevant, and achievable (WHO, 2014a; p. 3). Broadly speaking the plans were: (1) based on sound situation analyses with clear and relevant priorities and strategies; (2) developed on the basis of a sound and increasingly inclusive consultation process and they enjoyed high levels of political support both inside and outside the health sector; (3) had a sound and feasible financial framework that ensured financial sustainability; (4) accompanied by sound, though less detailed, systems for implementing and managing the programmes and activities contained in them; and (5) contained sound M&E frameworks that included clear indication of the types of reports and review processes that would keep implementation on track. This is what is required by the attributes in the JANS tool.

Closer inspection of the attributes and their associated criteria clearly show that some are met more closely than others. But there are only a few where it would have been desirable to have more information in the plans or where the plans did not fully meet the specified attribute or criterion. For example, Attribute 4 and criterion 1.4.1 require an assessment of potential obstacles to successful implementation, as well as mitigation strategies. In Turkey’s plans, this is limited to inclusion among the weaknesses in the SWOT analysis (p. 39 in SP1 and p. 59 in SP2) of “occasional resistance to innovation and change”. However, the approach utilized to implement the strategies is described in Akdağ (2012; pp. 46–47) and includes a pilot phase before rollout to the entire country, allowing the implementers to discover and rectify potential problems.

In addition, a management team was established under the chairmanship of the Deputy Undersecretary with the aim of addressing any psychological fall out, e.g., anxiety, resulting from the changes brought about by the reforms. Complementing the activities of this team was a number of field coordinators who conducted (tens of) thousands of site visits to all levels and types of health care providers to carry out on-site evaluations and to help resolve implementation problems (Ministry of Health, 2010a). Thus, while the plans may not have contained a detailed description of risk assessment and risk mitigation plans, in reality, they were an integral (and effective) part of the strategic implementation approach utilized by the Ministry of Health.

Attribute 5 and criterion 2.5.1 mandate meaningful multistakeholder involvement in the development of the national strategy. While both SP1 and SP2 had extensive consultations with a variety of internal and external stakeholders, it was considerably more meaningful in SP2 than in SP1, where the plan gives the impression that it was more of a pro forma exercise in response to a regulation. Furthermore, prior to SP1, i.e., during SP0, when there was no mandate for

21

multistakeholder involvement, it was in fact very limited. However, given the urgency of the situation and the need to begin implementation immediately, there would have been no time to go through a full-fledged consultation process as carried out years later.

Regarding the attributes related to the costs and financing of Turkey’s strategic plans, SP1 and SP2 are based on regular, three-year medium-term financing programmes as required by Public Law No. 5018 to ensure financial sustainability of all government programmes (Republic of Turkey, 2012). The same law also mandates the development of performance-based budgets; accordingly both SP1 and SP2 include such budgets. These plans do not contain information about how the costs estimates were derived. As a result, it is not a priori possible to determine whether they are realistic, but given the successful achievement of the strategic goals and objectives to date, it is clear that past cost estimates have been realistic and fully financed, providing assurance that the current estimates are also realistic and feasible. It should be noted that Turkey has experienced strong economic growth in all years since 2002, except 2008 and 2009 during the global economic crisis, making cost containment less of an issue.

Furthermore, because the Government from the beginning in 2002 placed such strong emphasis on improving outcomes, funding was not seen as a real constraint (WHO, 2012b). Finally, public expenditures on health in Turkey had traditionally been very low – among the lowest (both in absolute and relative terms) in the WHO European Region (2014b) – and there was a recognition that they would have to increase, if performance was going to improve (WHO, 2012b).

Regarding the implementation and management of Turkey’s strategic plans, the above-mentioned strategic implementation approach is both sound and effective. While information about the detailed aspects of the strategic implementation arrangements is limited in the plans themselves, that information is in operational action plans. Issues related to the need for institutional capacity building and strengthening of financial management and procurement systems were tackled more broadly by the Government of Turkey as part of European Union accession plans, but the SWOT analyses and associated strategic objectives (and subobjectives) also addressed some of these issues.

In contrast, the M&E and review aspects of Turkey’s strategic plans are very strong. Not only is there an overall framework, but also measurable performance indicators with both baselines and targets. Furthermore, as discussed in Section 7, improvement in the quality of the performance indicators over the years has been noticeable.

In summary, Turkey’s strategic plans, particularly SP2, come very close to the so-called sound standard established by IHP+ for such plans. Furthermore, what is not in the actual plans exist elsewhere, which of course is what is important. That is not to say that there are not ways in which strategic planning could be strengthened in Turkey. This is the subject of the next section.

9. RECOMMENDATIONS FOR THE CONTINUED DEVELOPMENT OFSTRATEGIC PLANNING The above analysis clearly shows that strategic planning not only has been successful but has been evolving in a positive direction.The first recommendation is therefore to continue the positive developments. In particular, it would be important for Turkey to continue certain steps.


Use strategic planning as an integral part of strategic management. Broaden the engagement of stakeholders in the strategic planning process, particularly, in the annual reporting

of progress on the indicators. Expand its noteworthy multisectoral cooperation in health, in particular in the area related to the social

determinants of health. Build the capacity of relevant Ministry of Health (and other) staff to prepare strategic planning and to effectively

utilize them as a management tool in their efforts to achieve their targets. Use strategic planning in the allocation of resources and further refine the programme-based budget developed

for 2014 in order to allow greater flexibility in spending within different programme categories.

The second recommendation is to identify activities that hold promise to increase the effectiveness of the SP. These include first, to broaden the dissemination of SP2 within the Ministry of Health and affiliated organizations in order to exploit its potential as a communication and motivation tool. Strategic planning is often touted as a vehicle for communicating the organization’s goals and strategies and as a mechanism for building ownership. Given the impressive progress made by the HTP, senior management might take the opportunity of the annual reviews of progress towards the strategic objectives not only to identify potential problem areas to be addressed, but also to build pride in the results that have been achieved.

Another area where the Ministry could further exploit the benefits of its M&E activities concerns health system performance assessment, the institutionalization of which is one of the objectives (Objective 4.2.1) in SP2. It would be beneficial to ensure closer linkage between the health system performance assessment and the strategic planning to tackle performance issues, particularly those related to equity/distributional concerns.

Another possibility of increasing the impact of the strategic plan would be to ensure that the situation analysis goes beyond the mandated SWOT analysis. As noted above, a traditional SWOT analysis does not uncover the root causes of the performance problems that the strategic planning is intended to address. As a result, they may go unnoticed, thereby undermining the likelihood that objectives and performance targets can be achieved. Again, so far this has not been a significant problem because the original HTP was based on an excellent diagnosis of the root causes of the problems. The HTP reforms were specifically developed to address these problems, with the remaining reforms included in SP1 or SP2. However, at some point new root causes will arise and, if not addressed, continue to cause performance problems.

One way to ensure that future strategic plans contain such analysis would be to further develop the content of the “Strategic Issues” section to include, at the beginning, a root-cause analysis, which would form the basis for identification of the strategic issues that the organization (and the strategic plan) has to address. The strategic themes, currently named “Strategic Issues”, would then follow naturally from this analysis. Such an approach would remedy the need to include deeper diagnostic analyses in the strategic planning, as well as correct the terminology used without changing the title of the section.

Related to issue of challenges, the strategic plan would be strengthened if it could address explicitly the key weaknesses identified in the SWOT analysis, which has not always been the case. Both SP1 and SP2, for example, state that “despite gradual decrease in bureaucracy and paperwork, failure to reach the desired speed in process and procedures” continues to be a weakness (Ministry of Health, 2010b p. 39; 2012a p. 59).

23

The final recommendation grows out of the Ministry of Health’s willingness to learn from other countries and to use evidence about what works. While the importance of evidenced-based medicine and evidence-informed policies are well known (Fielding & Briss, 2006), in practice knowledge transfer and diffusion of technologies is often both difficult and slow (Guldbrandsson, 2009).Turkey’s willingness to learn from, and implement, evidence-informed policies thus provides a unique opportunity to take advantage of recent evidence from both medical and social science research.

Two areas hold particular promise because they address one or more of the strategic objectives in SP2: evidence about what motivates people unleashing people’s creative potential.

Economists have long argued, and Turkey has experienced the positive impact of economic incentives on productivity, so there is little doubt that they can be very effective in motivating people to improve their performance. However, recent evidence suggests that under certain circumstances, e.g., when a product requires sophisticated intellectual input, such incentives may actually be counterproductive (see Pink (2009) for a discussion of this research). In those cases, what motivates people turns out to be three factors: autonomy, mastery and purpose.

In this context, autonomy refers to an individual’s ability to decide what s/he works on, how s/he does it, etc. and is not related to the concept of autonomy of institutions or political entities. Mastery concerns an individual’s skill level while purpose describes the reason why s/he does something. In other words, people’s motivation is linked to the degree of autonomy they have at work, a desire to master a skill or to become the best at something, and a sense that the work that they do serves a clearly defined purpose.

Improving motivation in the health sector is important for a number of reasons. Not only does it improve productivity, but also makes people more willing to endure potentially difficult changes. Moreover, evidence suggests that higher motivation is associated with reduced medical errors in hospitals (Vidal, 2002). Thus, improving the motivation of the medical staff would not only make for happier employees, but also could contribute to the reduction of the costly and unnecessary morbidity, mortality and productivity losses resulting from such errors.

It should be emphasized that Pink (2009) does not say that money is not important, but rather that money is important only up to a threshold level above which it is no longer serves as a motivating factor, at least for more complex tasks. Differences in pay among same level of staff can, however, result in discontent and demotivation, which can not only undermine productivity, but also result in increased turn-over among the lower-paid staff. Large discrepancies in remunerations of managers, for instance, employed at the Ministry of Health and others employed in hospitals poses a potential long-term challenge to the ability of the Ministry to retain its senior managers who play a crucial role in the continued success of the strategic management system.

The second area where Turkey might seek inspiration is in its efforts to increase innovation in the health sector (objective 4.3). The Government of Turkey could set up earmarked funds to establish the Turkish equivalent of Stanford University’s Bio-X initiative, which has been highly successful in catalysing interdisciplinary research leading to new knowledge and innovative technologies in a variety of biological areas that benefit human health (Stanford University, 2014). By specifying the type of innovation that it seeks to support and providing seed funding, the Ministry of Health could help unleash the creative talents of those working in the health sector (and beyond).


A similar approach could be used to fund initiatives intended to improve quality of care, in particular, measurable outcomes. Such an initiative could also be supported by the types of approaches that the SWITCH framework for behaviour change (Box 1) suggests would facilitate behavioural changes (Heath & Heath, 2011). This framework suggests that “for things to change, somebody somewhere has to start acting differently”. It does not have to be the top leader, it could be anyone person or teams of people. To motivate others to change, Heath & Heath argue that a person has two sides: an emotional so-called elephant side and so-called rider side, and that both sides must be influenced, and a path cleared for them to succeed (Heath & Heath, 2011).

The above examples hold great potential for additional improvements in health system performance, and are entirely consistent with Turkey’s desire to increase autonomy in the health sector and then hold people accountable for results, moving away from bureaucratic control over inputs, which often do not work well.

10. LESSONS LEARNT

Turkey’s experience with strategic planning holds a number of lessons for other countries wishing to strengthen, or begin, their own strategic planning. First, strategic planning should only be done as part of a broader strategic

direct the rider

motivate theelephant

shape the path

Source: reproduced with permission from Health & Heath (2014).

Direct the rider.

- Follow the bright spots.

- Investigate what is working well and clone it.

- Script the critical moves.

- Do not think big picture; think in terms of specific behaviours.

- Point to the destination. Change is easier when you know where you are going and why it is worth it.

Motivate the elephant.

- Find the feeling. Knowing something is not enough to cause change. Make people feel something.

- Shrink the change. Break down the change until it no longer spooks the elephant.

- Grow your people. Cultivate a sense of identity and instil the growth mindset.

Shape the path.

- Tweak the environment. When the situation changes, the behaviour changes. So change the situation.

- Build habits. When behaviour is habitual, it is free – it does not tax the rider. Look for ways to encourage habits.

- Rally the herd. Behaviour is contagious. Help it spread.

BOX 1. THE SWITCH FRAMEWORK FOR CHANGE

Source: adapted with permission from Heath & Heath, 2014

25

management process where as much attention is paid to (strategic) implementation and (strategic) control as to planning. As long as 150 years ago Florence Nightingale knew that “reports are not self-executive” (quoted in Barth, 1945), yet many countries have proceeded to ignore this important axiom, wasting valuable time and resources on a strategic planning process that led nowhere. Thus, only prepare a strategic plan, if it is going to be implemented, which requires operational plans, sufficient resources (both human and financial), as well as administrative and managerial capacity to do so. Furthermore, design a monitoring and evaluation system that can serve as a management tool to measure progress towards operational and strategic plan objectives and goals.

In this context, the JANS assessment tool provides excellent information about what should be contained in a sound strategic plan, but as Turkey’s experience shows, it is not so much what is in the plan that is important as what actually gets done. Including everything in a plan is merely a way to ensure that nothing is overlooked or forgotten.

Another important lesson from Turkey’s experience with strategic planning (and echoed in JANS) is the importance of carrying a careful diagnosis of the root causes underlying the observed performance problems in order to identify possible reforms or other health system strengthening initiatives that will need to be carried out, if the performance is to improve. As documented in Turkey, a traditional SWOT analysis – the traditional situation analysis – seems not an appropriate tool to identify the complex and interlinked reforms needed if major improvement in health system performance is the goal. This is not to say that a SWOT analysis a waste of time but rather, it is insufficient by itself.

In this context, countries would be well served to begin their situation analysis with the same kind of health system performance assessment as that carried out in Turkey, because that will help to identify national performance priorities, as well as equity concerns for inclusion in the strategic plan. Such an exercise will also help identify improvements to the M&E system, as traditional administrative data sources are usually inadequate to carry out the kind of subgroup analysis needed to analyse distributional gaps.

Turkey’s strategic planning experience also documented the importance of developing evidence-based (or -informed) policies and programmes to address the root causes underlying the identified performance problems. Akdağ (2012) recommends that the health transformation team “know the literature”, “get suggestions” from experts and other countries, “make rapid assessments” when reasonable evidence is available and when not, “support good policy research” (pp. 42–43).

For countries wishing to use strategic planning as part of an effort to transform their health sector, it should be emphasized that political leadership both within the Ministry of Health and from the top level of the Government of Turkey was a critical element of the success of the HTP. Without such a whole-of-government approach, it would have been impossible to resolve the situations in which the reforms were deadlocked because of disagreement about the direction of reform, as was the case in Turkey with respect to reforms of the social health insurance system, which was beyond the jurisdiction of the Ministry of Health (WHO, 2012b).

Political support is also one of the important attributes noted in the JANS tool. Here too, Turkey’s experience may provide inspiration, if the needed external support is lacking when the process is initiated. In that case, such support may be generated if initial reforms and interventions can produce enough improvement in performance to generate political support from the population at large. The initial improvements in health system performance can help generate the political capital necessary to complete the remaining (and harder) reforms. It also helped ensure a political stability over a long period of time that also contributed to the success of the HTP.


In this context, getting reforms off the ground and generating quick wins rather than embarking on large stakeholder consultations resulted in an effective way to build trust among stakeholders and engage them into more structural, long-term, health reforms.

11. CONCLUSIONS Turkey has transformed its health system and achieved impressive health gains. These achievements were the results of comprehensive reforms of the health system, but sustained economic growth and political stability also played important roles.

This report documented the role that strategic planning has played in the success of the health reforms, but also notes that strategic planning in Turkey was part of a wider framework of strategic management, which the Government of Turkey initiated in 2002 and which it has continued to promote through the development and implementation of supportive legislation and regulations.

In the strategic management approach used in Turkey, strategic planning is accompanied by strategic implementation and strategic control (M&E). The success of the HTP is therefore not only due to effective strategic planning, but also the strategic implementation and the strong M&E framework used throughout to identify potential problems and rectify them.

Traditional models of strategic planning include a large number of steps and the inclusion of many stakeholders in the process. The Ministry of Health used the essential aspects of strategic planning to get the HTP off the ground quickly, and then used early successes to build the political support necessary to complete the more difficult reforms. At the same time, it developed the capacity to prepare full-fledged and officially approved strategic plans that involve myriad stakeholders and incorporate their feedback into the plan. Today, Turkey’s strategic plan comes close to what might be defined as the so-called sound standard for such plans as defined by IHP+.

Turkey’s impressive success with strategic planning holds a number of lessons for countries wishing to initiate or strengthen their strategic planning capacity or transform their health systems in a profound way. But an essential factor in the success of Turkey’s strategic planning (and implementation of its plans) was the strong leadership in the Ministry of Health and the high-level support provided by the top leadership in the Government of Turkey. Without high-level political commitment, embarking on a strategic planning process is unlikely to lead to meaningful improvements in performance.

Another important lesson from Turkey is that in a health system with a great degree of mistrust between the key stakeholders, it may be better to use an informal approach to identify quick wins that can help develop the needed trust among the stakeholders to carry out the more difficult reforms. Regardless of the process used, it is hard to imagine any country successfully transforming their health system in a relatively short period of time without effective strategic planning (and strategic implementation and control).

27

REFERENCES7

Akdağ R (2011). Turkey Health Transformation Program – Evaluation Report (2003–2010). Ankara: Ministry of Health.

Akdağ R (2012). Turkey Health Transformation Programme – Assessment Report (2003–2011). Ankara: Ministry of Health.

Andersen E (2013). Why strategic plans fail to deliver. In: Public Sector Digest. Ontario: Public Sector Digest. 16 December 2013 (http://www.publicsectordigest.com/blogs/view/36).

Armstrong E (2005). Integrity, Transparency and Accountability in Public Administration: Recent Trends, Regional and International Developments and Emerging Issues. New York (NY): United Nations (http://unpan1.un.org/intradoc/groups/public/documents/UN/UNPAN020955.pdf).

Barth RS (1945). Fiery angel: the story of Florence Nightingale. Coral Gables (FL): Glade House, Publishers.

Blackerby P (2014). History of Strategic Planning. In: Blackerby Associates [website]. Phoenix (AZ): Blackerby Associates, Inc. (http://www.blackerbyassoc.com/history.html).

Bryson JM (2011). Strategic Planning For Public And Nonprofit Organizations - A Guide to Strengthening and Sustaining Organizational Achievement, fourth edition. San Francisco (CA): Possey-Bass.

Çağlar E, Acar O (2013). An assessment on [sic] the Tenth Development Plan. Ankara: The Economic Policy Research Foundation of Turkey (tepav) (http://www.tepav.org.tr/upload/files/1378461158-4.An_Assessment_on_the_Tenth_Development_Plan.pdf).

European Commission. (2009). Turkey TR07-IB-FI-02, Gap Analysis Report, Activity 1.2. Brussels: European Commission.

Fielding JE, Briss PA (2006). Promoting Evidence-Based Public Health Policy: Can We Have Better Evidence and More Action? Health Aff. 25:969–78. doi: 10.1377/hlthaff.25.4.969.

Gorun M, Emini FT (2011). The Legal Framework of Strategic Management Implementations in Public Institutions in Turkey. British Journal of Arts and Social Sciences; 3:220–8.

Guldbrandsson K (2009). From news to everyday use. The difficult art of implementation. Östersund: Swedish National Institute of Public Health (http://www.who.int/management/district/services/FromNewstoEverydayUse.pdf).

Heath C, Heath D (2011). Switch: How to change things when change is hard. London: Random House Business Books.

Heath C, Heath D (2014). Switch Framework: How to make a switch. Heath Brothers (http://heathbrothers.com/download/switch-framework.pdf).

7 All websites were accessed on 16 December 2014.


IHP+ (2011). Joint Assessment of National Health Strategies and Plans – Joint Assessment Tool: the attributes of a sound national strategy. Version 2: September 2011. International Health Partnership (http://www.who.int/workforcealliance/knowledge/toolkit/24_1.pdf).

IHP+ (2012). Joint Assessment of National Health Strategies (JANS) Tool & Guidelines. In: ihp+ [website]. International Health Partnership+ (http://www.internationalhealthpartnership.net/en/tools/jans-tool-and-guidelines/).

Kanavos P, van den Aardweg S, Schurer W (2012). Diabetes expenditure, burden of disease and management in 5 EU countries. London: LSE Health, London School of Economics and Political Science.

Lucid B, Lepidi K (2011). What gets measured gets done. In: ALN Magazine [website]. Advantage Business Media (http://www.alnmag.com/articles/2011/04/what-gets-measured-gets-done).

MedlinePlus (2014). A1c Test. In: MedlinePlus [website]. A.D.A.M., Inc. (http://www.nlm.nih.gov/medlineplus/ency/article/003640.htm).

Merriam-Webster (2014). Strategy. In: Merriam-Webster [online dictionary]. Merriam-Webster (http://www.merriam-webster.com/dictionary/strategy).

Ministry of Health (2010a). Health Transformation Program in Turkey – Progress Report, September 2010. Ankara: Ministry of Health. (http://www.saglik.gov.tr/EN/dosya/2-1251/h/healthtransformationprogrammeinturkey.pdf).

Ministry of Health (2010b). Strategic Plan 2010–2014. Ankara: Ministry of Health. (http://ekutuphane.sagem.gov.tr/kitap.php?id=240&k=strategic_plan_2010_2014).

Ministry of Health (2012a). Strategic Plan 2013–2017. Ankara: Ministry of Health (http://www.sgb.saglik.gov.tr/content/files/stratejikplanEng/index.html).

Ministry of Health (2012b). Health Statistics Yearbook 2011. Ankara: Ministry of Health.

Ministry of Health (2013a). Health Statistics Yearbook 2012. Ankara: Ministry of Health.

Ministry of Health (2013b). Program for Improving Multisectoral Health Responsibility 2013–2023. Ankara: Ministry of Health.

Ministry of Health (2014). Dr Mehmet Müezzinoğlu. In: Ministry of Health [website]. Ankara: Ministry of Health (http://www.saglik.gov.tr/BAKAN/belge/1-12236/english.html).

Organisation for Economic Co-operation and Development (2005). Paris Declaration on Aid Effectiveness and the Accra Agenda for Action. Organisation for Economic Co-operation and Development (http://www.oecd.org/dac/effectiveness/parisdeclarationandaccraagendaforaction.htm).

Oxford University Press (2014). Definition of strategy in English. In: Oxford Dictionaries [online dictionary]. Oxford University Press (http://www.oxforddictionaries.com/definition/english/strategy).

29

Pink DH (2009). Drive: The Surprising Truth About What Motivates Us. New York (NY): Riverhead Books.

Republic of Turkey (2011). Decree Law No. 663 On Structure and Duties of The Ministry of Health and Affiliated Institutions. Official Gazette No. 28103 dated 2 November 2011.

Republic of Turkey (2012). Public Financial Management and Control Law No. 5018. Ankara: Republic of Turkey, Ministry of Finance, Strategy Development Unit. (http://www.sgb.gov.tr/Mevzuat/01.Kanun/Public%20Financial%20Management%20and%20Control%20Law%20No.%205018.pdf).

Stanford University (2014). About. In: Stanford Bio-X [website]. Stanford (CA): Stanford University (https://biox.stanford.edu/about).

T.R. Prime Ministry, State Planning Organization (2007). Ninth Development Plan 2007–2013. Ankara: T.R. Prime Ministry, State Planning Organization.

Turkey Statistical Institute (2012). Health Survey 2010. Ankara, Turkey: Turkey Statistical Institute. (http://www.who.int/fctc/reporting/party_reports/turkey_annex2_turkish_health_survey_2010.pdf).

Turkey Statistical Institute (2013). Health Survey 2012. Ankara, Turkey: Turkey Statistical Institute. (http://www.turkstat.gov.tr/Kitap.do?metod=KitapDetay&KT_ID=1&KITAP_ID=223). Turkish Statistical Institute (2014). Turkstat.gov.tr [website]. Ankara: Turkish Statistical Institute (http://www.turkstat.gov.tr/UstMenu.do?metod=temelist).

Vidal Y (2002). 101 Ways to Prevent Medical Errors. Florissant (MO): Lara Publications.

WebFinance, Inc. (2014). Strategic planning. In: BusinessDictionary.com [online dictionary]. Washington (DC): WebFinance, Inc. (http://www.businessdictionary.com/definition/strategic-planning.html#ixzz2vmdC7sgn).

Wenar L (2006). Accountability in International Development Aid. Ethics and International Affairs; 20:1–23.doi: 10.1111/j.1747-7093.2006.00001.x.

WHO (2010). A Framework for National Health Policies, Strategies and Plans. Geneva: World Health Organization (http://www.who.int/nationalpolicies/FrameworkNHPSP_final_en.pdf).

WHO (2014a). How to conduct a Joint Assessment of a National Health Strategy (JANS), based on country experience. A Working Document on Options for conducting a JANS on a health sector or sub-sector strategy. Version 2 – August 2013. Geneva: World Health Organization (http://apps.who.int/iris/bitstream/10665/128671/1/9789241507318_eng.pdf).

WHO (2014b). WHO Global Strategy on People-centred and Integrated Health Services. In: World Health Organization [website]. Geneva: World Health Organization (http://www.who.int/servicedeliverysafety/areas/people-centred-care/en/).

WHO Regional Office for Europe (1998). Health21 – health for all in the 21st century. Copenhagen: WHO Regional Office for Europe (http://www.euro.who.int/__data/assets/pdf_file/0003/88590/EHFA5-E.pdf).


WHO Regional Office for Europe (2008). The Tallinn Charter: Health Systems for Health and Wealth. Copenhagen: WHO Regional Office for Europe (http://www.euro.who.int/en/publications/policy-documents/tallinn-charter-health-systems-for-health-and-wealth).

WHO Regional Office for Europe (2012a). European Action Plan for Strengthening Public Health Capacities and Services. Copenhagen: WHO Regional Office for Europe (http://www.euro.who.int/en/health-topics/Health-systems/public-health-services/publications2/2012/european-action-plan-for-strengthening-public-health-capacities-and-services).

WHO Regional Office for Europe (2012b). Successful health system reforms: the case of Turkey. Copenhagen: WHO Regional Office for Europe.

WHO Regional Office for Europe (2012c). Tobacco control in Turkey: story of commitment and leadership. Copenhagen: WHO Regional Office for Europe (http://www.euro.who.int/en/countries/turkey/publications/tobacco-control-in-turkey-story-of-commitment-and-leadership).

WHO Regional Office for Europe (2012d). WHO Regional Committee for Europe resolution EUR/RC62/R4 on Health 2020 – The European policy framework for health and well-being. Copenhagen: WHO Regional Office for Europe (http://www.euro.who.int/__data/assets/pdf_file/0005/173651/RC62rs04-Health-2020-ENG.pdf?ua=1).

WHO Regional Office for Europe (2013). Health 2020. A European policy framework and strategy for the 21st century. Copenhagen: WHO Regional Office for Europe (http://www.euro.who.int/en/health-topics/health-policy/health-2020-the-european-policy-for-health-and-well-being/publications/2013/health-2020-a-european-policy-framework-and-strategy-for-the-21st-century).

WHO Regional Office for Europe (2014). European Health for All database [online database]. Copenhagen: WHO Regional Office for Europe (http://data.euro.who.int/hfadb/).

Wikipedia (2014). Strategic planning. In: Wikipedia, The Free Encyclopedia [website]. Wikimedia Foundation, Inc. (http://en.wikipedia.org/wiki/Strategic_planning).

31

ANNEX 1. REFORMS AND HEALTH SYSTEMSTRENGTHENING INITIATIVES (2003–2013)

Tables A1.1–A1.3 show the achievements associated with the three strategic plans (Akdağ, 2012; Ministry of Health, 2010; 2012).

Year Achievement

2003 We put an end to [patients] being held in pledge [hostage in hospitals until payment for services was made].

We made 112 emergency health care services entirely free of charge.

We started the scaling up of free mobile health care services in rural areas.

We enabled the citizens to access the services provided by private hospitals and medical centres using their health insurance.

We initiated total quality management (TQM) implementation in the Ministry of Health.

We started performance-based supplementary pay system. Therefore, we insured full-time practice for physicians in hospitals and we substantially reduce patients’ need to apply to private practice.

We started the “one examination room for each position” practice in health facilities affiliated with the Ministry of Health [to end the practice of physicians sharing one examination room].

We launched the transition from ward to room system (including bed and bathroom).

2004 We started the free-of-charge distribution of iron supplements and vitamin D to babies and pregnant women.

We started to establish free-of-charge cancer screening and training centres (KETEMs).

Was started to implement a personal performance-based payment system in Ministry of Health institutions.

We included outpatient services in the benefits package of Green Card holders. [The Green Card Programme is a non-contributory health insurance programme].

We started the implementation of the right to choose a physician in Ministry of Health hospitals.

We started implementation of a conditional cash transfer [programme].

We compensated retroactive health care payments of all citizens who had been entitled to have [a] Green Card but had not been able to get one before getting sick.

Establishment phase of the [National Medical Rescue Teams] NMRTs for which training and establishment procedures started in 2003 was concluded.

We started implementation on a reference price system for medicines.

We put [the Health Information Communication Centre] SABIM into service.

2005 We enabled 37 million enrolees from [social insurance agencies] SSK to benefit from public hospitals by uniting public cost pools under a single roof.

We enabled Green Card holders to benefit from public health care services like other insured citizens and we enabled them to get their medicine from any pharmacy.

TABLE A1.1. HEALTH TRANSFORMATION PROGRAMME (2003–2009)


Year Achievement

2005(continued)

We included institutional criteria and quality criteria in performance-based payment systems in Ministry of Health institutions.

We started a family medicine pilot implementation in Duzce province.

We introduced [a] Patient Rights unit in every Ministry of Health hospital.

We introduced compulsory public service for physicians.

2006 We started global budget implementation for Ministry of Health hospitals.

We initiated enforcement of Law No. 5502 (Integration of social security institutions).

The Law on Public Private Partnership was adopted by the Grand National Assembly of Turkey.

We included measles, mumps and rubella vaccines in routine vaccination programmes.

We scaled up [Directly Observed Treatment] DOT implementation for tuberculosis patients countrywide.

We started a screening programme for hyperthyroidism.

2007 We enabled all citizens to access primary care services free of charge.

We terminated the referral obligation from Ministry of Health hospitals to University hospitals for enrolees of SSK and [the Social Insurance Agency for Merchants, Artisans and Self-employed] Bağ-Kur.

We initiated bundle (fixed) payment based on an ICD–10 for outpatient and inpatient procedures in all [Social Security Institute] SSI–contracted Ministry of Health hospitals, University hospitals and private hospitals.

We started an implementation for SSI–contracted hospitals including the free supply of medicine and medical equipment (under insurance coverage) and the sanctioning of hospitals receiving payment from patients.

We expanded coverage for Green Card holders to include outpatient expenses for medical examinations, test- analysis, medicine, dental extraction, dental prosthesis, eyeglasses and emergency care.

We procured ambulances with continuous tracks to provide accessibility in areas with hard winter conditions.

We started an implementation for SSI–contracted hospitals including the free supply of medicine and medical equipment for hospitalized patients.

2008 We started providing emergency and intensive care treatments free of charge in all public and private hospitals.

We ensured that no additional payment is taken for the procurement of the following services in private hospitals: burns, cancer, neonatal care, tissue transplantation, congenital anomalies, dialysis and [cardiovascular surgery] CVS procedures.

We included people aged 18 years and under and students in [universal health insurance] UHI coverage without seeking Social Security.

We enabled every citizen (insured or non-insured) to benefit from free health care services in case of emergencies, epidemics, occupational accidents and occupational diseases.

We launched an air ambulance system.

We reduced premium payment to 30 days for SSK and Bağ-Kur enrolees with a view to enabling them to get health services.

For diseases that cannot be treated in Turkey, we provided all insured citizens with the option of receiving treatment in foreign countries.

At the Ministry of Health, we started planning private health facilities in terms of physicians and certain medical services.

We included pentavalent vaccines into routine immunization programmes.

33

Year Achievement

2008(continued)

The Grand National Assembly of Turkey adopted Public Law No. 5727 on the Prevention and Control of Hazards of Tobacco Products, which prohibits smoking in indoor public places, which was amended by Public Law No. 4207 on Prevention and Control of Hazards on Tobacco Products.

We launched the Guest Mother Project in order to welcome future mothers and provide them with healthy delivery conditions in places without easy access to transportation.

We launched the biotinidase scanning programme.

We started community-based mental health services.

We launched the Health Promotion Program.

2009 We started the [Pharmaceutical Tracking System] PTS pilot implementation.

We started the Central Patient Appointment System (CPAS) pilot implementation.

We introduced a rule that when the generic of an original product is placed on the market, the price of the product should not exceed 66% of the existing product’s price (both original and generic products).

We started mobile pharmacy implementation to ease the access of people living in rural areas to medicine.

We added the pneumococcal conjugate vaccine to the vaccination programme.

Source: adapted with permission from the Ministry of Health (Akdag, 2012).

Year Achievement

2010 We enabled Green Card holders to benefit from emergency and intensive care services in private hospitals free of charge.

We enabled Green Card holders to benefit from root canal therapy and dental filling free of charge.

We prepared the Full – Day Law regarding full-time working of university and health care personnel.

We started to provide home care.

We scaled up the PTS implementation countrywide.

We started studies on reducing bureaucracy and administrative simplification.

We included ambulance airplanes in the air ambulance group.

2011 We have restructured the Ministry of Health. In this scope, we have issued the decree on Organizations and Duties of the Ministry of Health and the Associated Institutions.

We made the prospectuses simpler and more comprehensible for citizens to understand all types of information about all drugs.

We rolled out the Central Hospital Appointment System (CHAS) across the country. Moreover, we made it possible to get an online appointment from CHAS via the Internet.

We initiated the White Code System to prevent violence against health professionals.

We made regulations on promotion and information activities to be carried out by private health institutions.

We specified the conformity criteria for composition tissue plantation.

We started to implement the Cardiovascular Disease Prevention and Control Programme of Turkey.

TABLE A1.2. STRATEGIC PLAN (2010–2014)


Year Achievement

2011(continued)

We published the Mental Health National Action Plan covering the period 2011–2023.

We provided smoking cessation medications free of charge to our citizens in smoking cessation centres.

2012 We started the evaluation period of performances of Public Hospitals Union and health facilities as part of the studies on the Evaluation of Public Hospitals Union.

We accelerated evaluation studies of quality in health. We made some changes in the sets of quality standards.

We developed the Health Tourism Action Report to deliver high quality and cheaper health services in health tourism.

Source: adapted with permission from the Ministry of Health (Akdag, 2012) and Ministry of Health (2010).

Source: adapted with permission from the Ministry of Health of Turkey (Ministry of Health of Turkey, personal communication, 12 December 2014).

Year Achievement

2013 We started to prepare the building process of 17 comprehensive city hospitals to be built in different regions and have laid the foundation of many.

We utilized electronic product codes from the Pharmaceutical Tracking System to obtain information on previous and current locations of products in the procurement and distribution process.

We introduced the Medical Tourism Evaluation Report in Turkey to increase the proportion of services of health facilities in medical tourism in Turkey (Republic of Turkey, Ministry of Health & Directorate of Health Services; 2012).

We introduced the project Voluntary Donor and Determination of Appropriate Sampling Protocol to establish the National Bone Marrow and Cord Blood Bank (TÜRKÖK).

We started the process of enhancing clinical quality and developed indicator panels for to provide feedback to hospitals.

Using mini-tracking devices (global positioning systems), we provided accurate and effective orientation of 112 Emergency Health Services for the National Medical Rescue Team (UMKE) personnel for disasters and emergencies and for personnel safety management.

We started legislation and regulation studies to convert our country into a regional centre of expertise, to accelerate the entrance of foreign capital and advanced medical technologies to Turkey.

We started studying how to improve and evaluate health service quality based on patient/employee safety and satisfaction.

We introduced an alcohol control programme.

TABLE A1.3. STRATEGIC PLAN (2010–2014)

35

REFERENCES


Ministry of Health (2010). Strategic Plan 2010–2014. Ankara: Ministry of Health. (http://ekutuphane.sagem.gov.tr/kitap.php?id=240&k=strategic_plan_2010_2014, accessed 16 December 2014).

Ministry of Health (2012). Strategic Plan 2013–2017. Ankara: Ministry of Health (http://www.sgb.saglik.gov.tr/content/files/stratejikplanEng/index.html, accessed 16 December 2014).

Republic of Turkey, Ministry of Health, Directorate of Health Services (2012). Evaluation Report on Medical Tourism in Turkey, 2012. Ankara: Republic of Turkey, Ministry of Health, Directorate of Health Services (http://www.saglik.gov.tr/SaglikTurizmi/dosya/1-79232/h/eng-medikal-turizm.pdf, accessed 18 December 2014).


ANNEX 2. BRYSON’S STRATEGIC PLANNING MODELAPPLIED TO THE HTP (2003–2009)8

1. INITIATE AND AGREE UPON A STRATEGIC PLANNING PROCESS

Given the quick speed with which the Minister of Health wanted to begin to implement changes, this step was completed very quickly, as was the planning process itself, since the HTP was announced in early 2003. Clearly, the planning done was not the usual type of strategic planning. It involved only a small team of advisors and there was no time to carry out the extensive and time consuming stakeholder consultations that are normally an important part of a strategic planning process.

2. IDENTIFY ORGANIZATIONAL MANDATES

The organizational mandates for the Ministry of Health are clear from the constitution. Article 60 of the 1982 Constitution of the Republic of Turkey declares “Everyone has the right to social security. The state shall take the necessary measures and establish the organisation for the provision of social security.” Furthermore, Article 56 proclaims that in order “To ensure that everyone leads (sic) their lives in conditions of physical and mental health and to secure cooperation in terms of human and material resources through economy and increased efficiency, the state shall regulate central planning and functioning of the health services. The state shall fulfil this task by utilizing and supervising the health care and social institutions both in the public and private sectors.” (Hellenic Resources Network, 2014).

3. CLARIFY ORGANIZATIONAL MISSION AND VALUES

This was an important step that laid the foundation for the HTP. Taking as inspiration WHO’s mandate that a health system should ensure “the delivery of high-quality health care services for all people” (Akdağ, 2011), the Minister and his team reviewed past experiences, explored models from other countries and ultimately defined the aim of the HTP as “to organize, finance and deliver the health services in an effective, efficient and equal fashion” (Ministry of Health, 2010). Values and principles underlying and guiding the development of the HTP were also clarified:

people-centredness sustainability continuous quality participation reconciliation volunteerism separation of powers decentralization competiveness in service.

4. ASSESS THE ORGANIZATION’S EXTERNAL AND INTERNAL ENVIRONMENTS TO IDENTIFY

STRENGTHS, WEAKNESSES, OPPORTUNITIES AND THREATS (SWOT) In place of a formal SWOT analysis, the Minister and his team carried out a diagnostic exercise to identify the root causes of the poor performance that characterized the health system in Turkey at that time (WHO Regional Office for Europe, 2012). Given the complex, inter-related performance problems such an analysis might actually have been more appropriate than a simple SWOT analysis, because it clarified the many health system dimensions that would have to be addressed if performance was to improve. In this effort, the Minister and his team were greatly

8 Bryson, 2011.

37

aided by the many reports and analyses that had been carried out during the previous decades, which clearly identified both the performance problems and (many) of their root causes (WHO Regional Office for Europe, 2012).

5. IDENTIFY THE STRATEGIC ISSUES FACING THE ORGANIZATION

The root-cause analysis served to identify the strategic issues facing the organization. They included, but were not limited to, inequitable and inadequate health insurance coverage, fragmented risk pools, limited and inequitable access to health care, absence of primary health care, inadequate numbers and inequitable distribution of human resources for health, unmotivated staff, inadequate and inequitably distributed infrastructure and equipment (WHO Regional Office for Europe, 2012; Akdağ, 2012).

6. FORMULATE STRATEGIES TO MANAGE THESE ISSUES

The HTP was the response to these (and other) strategic issues facing the health sector and it set out to address all the root causes of the performance problems (WHO Regional Office for Europe, 2012). The main strategies are listed in Section 3 while Annex 1 lists in chronological order the reforms and initiatives under the HTP.

7. REVIEW AND ADOPT THE STRATEGIC PLAN OR PLANS

In absence of a formal strategic planning process and an official plan, this step is not applicable.

8. ESTABLISH AN EFFECTIVE ORGANIZATIONAL VISION

While there may not have been an explicit organizational vision developed as part of the HTP, it is implicit in the aim of the programme, which could easily be reformulated as a vision statement, for example: “A Turkey in which all citizens, as people of the country with equal rights, enjoy access to health services on an equitable basis” (Ministry of Health, 2010).

9. DEVELOP AN EFFECTIVE IMPLEMENTATION PROCESS

While not enshrined in an official plan, one of the keys to the success of the HTP was the way in which (and the speed with which) it was implemented (WHO Regional Office for Europe, 2012). In particular, the establishment of field coordination teams to facilitate and monitor progress on the implementation of the reforms and regular site visits by the Minister and his teams to all the governorates to meet with key stakeholders, e.g., provincial governors, bureau of health directors, and hospital directors clearly indicate that significant attention was paid to the implementation process (Ministry of Health, 2010). Interestingly, part of the reason the reforms could be implemented so quickly was that there was little attempt to bureaucratize the process. Put different, the reforms were initially implemented without detailed instructions and regulations. The emphasis here was placed on speed rather than the development of detailed circulars (WHO Regional Office for Europe, 2012), as might normally have been the case in a well-established bureaucracy like Turkey’s.

10. REASSESS STRATEGIES AND THE STRATEGIC PLANNING PROCESS

This category would be more appropriately named “monitoring, evaluation, and follow-up action”, which is also the case in many other models of the strategic planning process (e.g., Mastrodonato, 2014). Monitoring and evaluation played an important role in the HTP. A variety of formal, as well as informal channels, of communication were established to provide real time information to the Minister and his team, who held regular meetings to monitor progress on the implementation of the reforms. Where problems were identified, action plans would be prepared and follow-up made on a quarterly basis. Should systemic problems be identified, the Minister would quickly address them. In addition to these efforts, progress towards the overall goals like health indicators, financial risk protection and population satisfaction was monitored on an annual basis (WHO Regional Office for Europe, 2012).


REFERENCES



Bryson JM (2011). Strategic Planning For Public And Nonprofit Organizations – A Guide to Strengthening and Sustaining Organizational Achievement, fourth edition. San Francisco( CA): Possey-Bass.

Hellenic Resources Network (2014). The Constitution of the Republic of Turkey, Chapter Three, Social and Economic Rights and Duties. In: HR-Net [website] (http://www.hri.org/docs/turkey/part_ii_3, accessed 16 December 2014).

Mastrodonato P (2014). Developing a strategic plan for your organization – A road map for the future. Saratoga Springs (NY): Nonprofit Works, Inc. (http://www.nonprofitworks.com/downloads/Outline_Basic%20Strategic%20Planning.doc, accessed 16 December 2014).

Ministry of Health (2010). Strategic Plan 2010–2014. Ankara: Ministry of Health (http://ekutuphane.sagem.gov.tr/kitap.php?id=240&k=strategic_plan_2010_2014, accessed 16 December 2014).

WHO Regional Office for Europe (2012). Successful health system reforms: the case of Turkey. Copenhagen: WHO Regional Office for Europe.

39

ANNEX 3. COMPARISON OF TURKEY’S STRATEGIC PLANS

Table A3.1 describes Turkey’s strategic plans from the Health Transformation Programme (HTP), herein called SP0, through SP2 in order to compare with the joint assessment of a national health strategy (IHI+, 2011) aspects, attributes and criteria.

Aspecta Attributeb No.c Criteriond HTP (2003–2009)

Strategic Plan2010–2014e

Strategic Plan2013–2017f

1. Situational analysis and programming

1. National strategies are based on a sound situation and response analysis of the context (including political, social, cultural, gender, epidemiological, legal, governance and institutional issues).

1.1.1 The situation analysis is based on a comprehensive and participatory analysis of health determinants and health outcome trends within the epidemiological, political, socioeconomic and organizational context prevailing in the country.

The Turkey HTP Evaluation Report (2003–2010) indicates that the programme was based on very comprehensive diagnostic analyses; however, the process was not particularly participatory (Akdağ, 2011).

The situation analysis includes only a description of resources and a SWOT analysis, no detailed diagnosis or trends. However, trend data were available through the monitoring and evaluation (M&E), Health System Performance Assessment (HSPA) was in the process of being completed in collaboration with WHO. The HSPA contains detailed analysis of trends and distributional issues related to health outcomes (WHO Regional Office for Europe, 2012 p. 22).

The situation analysis consists of a review of the accomplishments of HTP with respect to physical and financial access, quality, efficiency and health indicators, but has no explicit identification of performance problems to be addressed. This section also includes a description of existing resources and a SWOT analysis, but no detailed diagnosis of performance problems or analysis of trend data; however, the latter were available through the M&E system. Furthermore, Akdağ (2012) includes a detailed diagnosis performed for the HTP, suggesting that it was also applicable to SP2, which continued the implementation of HTP. In addition, the 2011 HSPA contains detailed analyses of both trends and distributional issues related to health outcomes (WHO Regional Office for Europe, 2012, p. 22).

1.1.2 The analysis uses disaggregated data to describe progress towards achieving health sector policy objectives in line with primary health care: universal coverage to improve health equity; service

The Turkey HTP Evaluation Report (2003–2010) contains detailed analyses on the progress towards achievement of health sector policy goals (Akdağ, 2011). While disaggregated data were not reported to the

As above, situation analysis includes only a description of resources and a SWOT analysis. No analysis based on disaggregated data. Some disaggregated data (e.g., by sex, region of residence) were available through the M&E system and subsequently used to

The review of the accomplishments of the HTP to date includes a description of progress toward universal coverage; service delivery, in particular, progress on family medicine; as well as progress on making the health system more people-centred, and improvements in health promotion services like immunization and prenatal care. The review includes a

TABLE A3.1.APPLICATION OF THE JANS TOOL TO TURKEY’S STRATEGIC HEALTH PLANS





delivery to make health systems people-centred; public policies to promote and protect the health of communities; and leadership to improve competence and accountability of health authorities.

Ministry of Health (2010a), some disaggregated data (e.g., by sex, region of residence) were available through the M&E system.

carry out the above-mentioned HSPA. (WHO Regional Office for Europe, 2012).

number of action plans to protect the health of individuals and communities.

1.1.3 Analysis of past and current health sector responses and health financing arrangements identifies priority problems and areas for improvement.

Contained in the Turkey HTP Evaluation Report (2003–2010) (Akdağ, 2011).

No longer relevant, as universal health insurance under a single framework was part of the HTP and implemented prior to 2010 (Ministry of Health, 2010a).

No longer relevant, as universal health insurance under a single framework was part of the HTP and implemented prior to 2010 (Ministry of Health, 2010a).

2. The national strategy sets out clear priorities, goals, policies, objectives, interventions and expected results that contribute to improving health outcomes in equity, and to meeting national and global commitments.

1.2.1 Objectives are clearly defined, measurable, realistic and time-bound.

The Turkey HTP Evaluation Report (2003–2010) documents that the HTP had clearly defined, measurable, realistic and time-bound objectives and indicators (Akdağ, 2011).

SMARTERf criteria were successfully used during the development of objectives/subobjectives to achieve the strategic goals, e.g., Objective 1.2 “To improve maternal, child and adolescent health and to reduce maternal mortality below 10 per 100 000 and infant mortality rate below 100 per 1000 by the end of 2012 (p. 55).

Objectives are clearly defined, measurable and realistic. The specific target to be met and the date by which it should be met are included with the performance indicators in Part 4 Strategic Implementation, e.g., one of the performance indicators for Strategic Objective 1.1 To develop health dietary habits, increase the level of physical activity and reduce the obesity rate in the adult population (aged 19+ years) from 30.3% (2011) to 25% by 2017 and to 20% by 2023 (p. 135).

1.2.2 Goals, objectives and interventions address health priorities, access, equity, quality and health outcomes across all population subgroups, especially vulnerable groups. This includes plans for financing health services

The Turkey HTP Evaluation Report (2003–2010) contains goals, objectives and interventions that address health priorities, quality and health outcome (Akdağ, 2011) but no data about population subgroups.

Strategic Goal 3 and associated objectives and subobjectives are devoted to ensuring equity and the needs of special populations (pp. 81–85).

Strategic Goal 3 and associated objectives and subobjectives are devoted to ensuring equity and the needs of special populations (pp. 108–110).

41




that identify how funds will be raised; address financial barriers to access; and minimize risks of impoverishment due to health care.

3. Planned interventions are feasible, locally appropriate, equitable and based on evidence and good practice, including consideration of effectiveness, efficiency and sustainability.

1.3.1 Planned approaches and interventions are based upon analysis of effectiveness and efficiency, and are relevant to the priority needs identified. The approaches to and pace of scale up look feasible considering past experience on implementation capacity and identify ways to increase efficiency.

The Turkey HTP Evaluation Report (2003–2010) documents that the approaches and interventions were evidence-based and relevant to priority needs. They were scaled up to the entire country after an initial pilot period of learning (Akdağ, 2011).

Guiding principles and values for the plan included “being scientific” (p. 46) and the Strategic Map (p. 47) explicitly includes “efficient and comprehensive personal health services” as important higher-level objectives (pp. 49–50). Akdağ (2012) also documents that approaches and interventions selected for implementation were evidence-based and relevant to priority needs. Like previous interventions, they were scaled up to the entire country after an initial pilot period of learning.

Guiding principles and values for the plan includes “evidence-based” (p. 68) and the Strategic Plan Matrix (p. 69) explicitly includes “efficient” as important higher-level objectives. Similarly, providing “effective and efficient health services” is part of the Strategic Map (pp. 122–123). This Strategic Plan continues the past tradition of selecting and implementing evidence-based approaches and pilot testing them prior to scale up across the country (Ministry of Health, personal communication, 2013).

1.3.2 The plan identifies and addresses key systems issues that impact on equity, efficiency and sustainability, including financial, human resource and technical sustainability constraints.

The Turkey HTP Evaluation Report (2003–2010) documents that all key systems that impacted equity, efficiency and sustainability were addressed by the reforms (Akdağ, 2011).

System issues were not explicitly included. Equity and efficiency are important values or policy objectives, but sustainability was not mentioned as a priority. However, since SP1 continues the implementation of the HTP, systems issues had already been identified and solutions were being implemented.

Key system issues were already identified and addressed in SP0 and SP1. Equity and efficiency continue to be important values and policy objectives. Sustainability takes on an important and visible role in SP2, especially related to financial sustainability and the sustainability of human resources for health (HRH), infrastructure and technology (cf. SO 2.8, SO 2.9 and SO 4.1).

1.3.3 Contingency plans for emergency health needs (natural disasters and emerging/re–emerging diseases), in

Akdağ (2011) documents significant upgrading of disaster preparedness plans, and compliance with

Part of Strategic Goal 1 and strategic objectives and subobjectives (pp. 53–64).

Part of Strategic Goal 1 and strategic objectives and subobjectives (cf. SP2: SO 1.5).





line with the International Health Regulations (IHR), are included in plans at all levels (WHO, 2008).

IHR, cf. responses to prevent the spread of avian influenza and the H1N1 virus (WHO, 2008).

4. An assessment of risks and proposed mitigation strategies are present and credible.

1.4.1 Risk analyses include potential obstacle to successful implementation. Mitigation strategies identify how these risks are being addressed.

Implicit given the successful implementation of HTP.

Not discussed directly but the SWOT analysis includes some obstacles to successful implementation (pp. 38–40). Akdağ, 2012 (p. 72), however, describes the implementation framework, which includes controlled local implementation in order to test feasibility and revise implementation strategies as needed (Akdağ, 2012; p. 72).

Not discussed directly but the SWOT analysis includes some obstacles to successful implementation (pp. 59). Akdağ, 2012 (p. 72), however, describes the implementation framework, which includes controlled local implementation in order to test feasibility and revise implementation strategies as needed (Akdağ, 2012; p. 72).

2. Process soundness and inclusiveness of development and endorsement process for the national strategy.

5. Multistake- holder involvement in the development of the national strategy and operational plans and multistakeholder endorsement of the final national strategy are in place.

2.5.1 A transparent mechanism exists, which ensures the lead of the government and meaningful participation of all stakeholders, so they can provide input systematically into strategy development and annual operational planning. Stakeholders include national and local government institutions; public representatives; civil society; private health care providers and development partners.

Evaluation reports indicate limited stakeholder consultations.

Developed with extensive (internal and external) stakeholder consultation. The specific impact of these consultations is unclear. No apparent stakeholder input into annual operation planning.

Developed with extensive (internal and external) stakeholder consultation, whose input had a documentable impact on the formulation of the strategic goals and objectives. No apparent stakeholder input into annual operation planning.

43




6. They are indications of a high level of political commitment to the national strategy.

2.6.1 Relevant sectoral and multisectoral policies and legislation, under the spirit of “health-in-all policies” in place to allow successful implementation.

No discussion of multisectoral policies and legislation in HTP in Turkey – Progress Report, September 2010 (Akdağ, 2010). However, in 2007, the 60th Government of Turkey added “Multidimensional health accountability for mobilization of the parties and intersectoral collaboration” (Ministry of Health, 2010b; p. 20).

Objective 2.8 and subobjective 2.8.1 specifically concerned with the development of a multisector health responsibility policy by the end of 2011 (p. 79).

Due to the alignment of SP2 goals and objectives with Health 2020 objectives (WHO Regional Office for Europe, 2013), SP2 takes a whole-of-society, as well as a whole-of-government approach, which is actually broader than, and therefore exceeds “the health-in-all policies” mandated in JANS 2.6.1 (IHP+, 2011).

2.6.2 The strategy notes challenges to implementing the needed regulatory and legislative framework and has approaches to overcome enforcement problems.

The HTP in

Turkey – Progress

Report, September

2010 contains a list of both implemented and planned changes in the legislative framework (Akdağ, 2010).

SWOT analysis (p. 39) identifies needed regulatory and legislative changes. No specific mention of approaches to overcome enforcement problems. Some mention of actual enforcement initiatives in Akdağ (2012) so issue addressed despite absence in SP1.

The regulatory and legislative framework had been changed, thus, this is no longer applicable.

2.6.3 Political commitment shown by provision for maintaining or preferably increasing government’s financing of the national strategy.

Akdağ (2010) documents the development of a “Medium-Term Financial Program” to ensure that expenditures are in line with strategic objectives and to ensure financial sustainability.

SP1 contains plan cost estimates each year of the plan for every strategic goal and strategic objective (pp. 115–117). A Medium-Term Financial Plan for 2010–2012 was prepared to ensure financial sustainability (Akdağ, 2012).

SP2 contains plan cost estimates each year of the plan for every strategic goal and strategic objective (pp. 153–155). A three-year, rolling Medium-Term Financial Plan is in place to ensure financial sustainability (Akdağ, 2012).

2.6.4 High–level (e.g., national assembly) politi-cal discussion and formal endorsement of the national health strategy and budget is planned, as appropriate to national context.

In absence of formal plan, not applicable.

The Grand National Assembly of Turkey (GNAT) does not endorse strategic plans, but approves the budget, which is based on them. The State Planning Organization reviewed the strategic plan and formally approved them.

GNAT does not endorse strategic plans, but it approves the budget, which is based on them. The State Planning Organization reviewed the strategic plan and formally approved them. As a first, SP2 was presented and discussed in GNAT.





7. The national strategy is consistent with relevant higher and/or lower level strategies, financing frameworks and plans.

2.7.1 The national health strategy, disease specific programmes and other substrategies are consistent with each other and with overarching national development objectives.

HTP is highly consistent with the first objective of Turkey’s 8th Development Plan (T.R. Prime Ministry & State Planning Organization, 2000; UNDG, 2000), as well as with the 9th Development Plan: “Making the health system effective” (T.R. Prime Ministry & State Planning Organization, 2007). A number of new disease-specific programs (e.g., Obesity Prevention and Control Program of Turkey, National Control Program for Chronic Airway Diseases were developed under HTP (SP1, p. 97). All were developed in line with overarching national development objectives.

Part 3 is devoted to documenting how the national health strategy, its goals and strategic objectives are consistent important high-level documents, including the 9th Development Plan (T.R. Prime Ministry & State Planning Organization, 2007), the 60th Government Program and Health21 (WHO Regional Office for Europe; 1998) as documented in Tables 10–12 (pp. 88–90). New disease specific programs to be developed (e.g., National Diabetes Prevention and Control Programme (p. 97)) and the already developed programs, which would be implemented (e.g., Obesity Prevention and Control Program of Turkey, National Control Program for Chronic Airway Diseases) under SP1, were all developed in line with overarching national development objectives.

Part 3 (Tables 6–8 on pp. 128–130) shows the linkages between SP2 and:the 9th Development Plan (T.R. Prime Ministry & State Planning Organization, 2007)the Tallinn Charter: : Health Systems for Health and Wealth (WHO Regional Office for Europe, 2008); and Health 2020 (WHO Regional Office for Europe, 2013).

Disease-specific programmes are updated and enhanced in accordance with SP2; new programmes are also been added (cf. Objectives 1.9– 1.10).

2.7.2 In federal and decentralized health systems, there is an effective mechanism to ensure subnational plans address main national-level goals and targets.

Not applicable Not applicable Not applicable

3. Costs and financing of the strategy – soundness and feasibility of the financial framework

8. The national strategy has an expenditure framework that includes a comprehensive budget/ costing of the

3.8.1 The strategies accompanied by a sound expenditure framework with the cost to plan the links to the budget.

In absence of a formal plan, unclear; but Law No. 5018 and related regulations mandate that budgets and resource allocations

Law No. 5018 and related regulations mandate that budgets and resource allocations be linked to their strategic plans (Republic of Turkey, 2012). SP1 contains

Law No. 5018 and related regulations mandate that budgets and resource allocations be linked to their strategic plans (Republic of Turkey, 2012). SP2 contains plan cost estimates each year of the plan for every strategic

45




programme areas covered by the national strategy.

It includes the current in investment financing required to implement the strategy, including costs of human resources, medicines, decentralized management, infrastructure and social protection mechanisms. When appropri-ate, the frame-work includes costs for activities and stakeholders beyond the public sector.

be linked to their strategic plans. (Republic of Turkey, 2012). Furthermore, resources were never a constraint in the implementation of the HTP (WHO Regional Office for Europe, 2012).

plan cost estimates each year of the plan for every strategic goal and strategic objective (pp. 115–117). Furthermore, a 3-year rolling Medium-Term Financial Plan was developed in order to ensure financial sustainability (Akdağ, 2012).

goal and strategic objective (pp. 153–156). Furthermore, a 3-year, rolling Medium-Term Financial Plan is place to ensure financial sustainability (Akdağ, 2012).

3.8.2 Cost estimates are clearly explained, justified as realistic and based on economically sound methods.

In absence of a plan, not applicable.

As the plan does not explain cost estimates, determining whether they were based on economically sound methods is not possible.

As the plan does not explain cost estimates, determining whether they were based on economically sound methods is not possible.

9. The strategy has a realistic financing framework and funding projections. If the strategy is not fully financed, there are mechanisms to ensure prioritization in line with overall objectives of the plan.

3.9.1 Funding projections include all sources of finance, specify financial pledges from key domestic and international funding sources (including lending) and consider uncertainties and risks.

In absence of a plan, not applicable.

The plan does not contain funding projections, but resources were never a constraint in the implementation of the HTP (WHO Regional Office for Europe, 2012).


3.9.2 Funding projections are realistic in the light of economic conditions, and medium-term expenditure plans and fiscal space constraints.

In absence of a formal plan, not applicable.


The plan does not contain funding projections, but resources are unlikely to be a constraint in light of the presence of the medium-term financing plan and continued economic growth.





3.9.3 If the level of financing is unclear or there is a financing gap, then the priorities for spending are spelt out with the consequences for results (either by showing the plans and targets under high, low, and most likely funding scenarios, or by explaining the process for determining spending priorities).

In absence of a formal plan, not applicable.

This issue was not addressed, but resources were never a constraint in the implementation of the HTP (WHO Regional Office for Europe, 2012).

This issue was not addressed, but resources are unlikely to be a constraint in light of the presence of the 3-year rolling medium-term financing plans; and continued economic growth.

4. Implemen- tation and management – soundness arrange-ments and systems for implementing and managing the programmes contained in these national strategies.

10. Operational plans are regularly developed through a participatory process and detail how national strategic objectives will be achieved.

4.10.1 Roles and responsibilities of implementing partners are described. If there are new policies or approaches planned, responsibility for moving them forward to implementation is defined.

Implementation approach included establishment of a plan and assigning tasks to them (Akdağ, 2012). Role of partners not relevant.



4.10.2 There are mechanisms for ensuring that subsector operational plans – such as district plans, disease programme plans and plans for agencies and autonomous institutions – are related and linked to the strategic priorities in the national health strategy.

Mechanisms not described, but the disease-specific programmes and action plans clearly documented the linkage to the strategic priorities.

Mechanisms not specifically described, but the disease-specific programmes and action plans, were updated to reflect the strategic priorities in SP1, indicating that a mechanism exists.

Mechanisms not specifically described, but the disease-specific programmes and action plans were updated to reflect SP2 strategic goals and priorities. Furthermore, each department, relevant agencies and autonomous institutions are mandated to prepare their own plans based on SP2.

47




11. The national strategy describes how resources will be deployed to achieve outcomes and improve equity, including how resources will be allocated to subnational level and non-state actors.

4.11.1 The organization of service delivery is defined and the strategy defines the roles and responsibilities for service providers and the resources they require.

It contains a general description of the organization of service delivery, while detailed information is contained in operational actions plans of the relevant institutions/departments.

It contains a description of the organization of service delivery, as well as the needed resources, while detailed information is contained in operational actions plans of the relevant institutions/agencies.

It contains a description of the organization of service delivery, as well as the needed resources, while detailed information is contained in operational actions plans of the relevant institutions/agencies.

4.11.2 Plans have transparent criteria for allocation of resources (human resources, commodities, funding) across programme and to subnational levels and non-state actors (where appropriate) that will help to increase equity and efficiency.

In absence of a formal plan, cannot determine transparency criteria, but with equity and efficiency as important values and objectives and with the documented positive impact on both, both must have been criteria for resource allocation (Akdağ, 2012).

No explicit criteria for resources allocation included, but with both efficiency and equity as important values and objectives of SP1, and with several strategic objectives devoted to achieving them, they are at least implicitly used in resource allocation decisions.

No explicit criteria for resources allocation included, but with efficiency, equity and transparency as important values and objectives of SP2, and with several strategic objectives devoted to achieving them, they are at least implicitly used in resource allocation decisions.

4.11.3 Current logistics, information and management system constraints are described, and credible actions are proposed to resolve constraints.

Upgrading of logistics, information and management systems was an important part of HTP (Akdağ, 2012).

Upgrading of logistics, information and management systems was an important part of HTP and continued under SP1.

Upgrading of logistics, information and management systems was an important part of HTP and continued under SP2.

12. The adequacy of existing institutional capacity to implement the strategy has been assessed and their plans to develop the capacity required.

4.12.1 Human resource (management and capacity) needs are identified; including staffing levels, skills mix, distribution, training, supervision, pay and incentives.

HRH (both medical and managerial) trained, regulated and provided with incentives (Akdağ, 2012).

The (continued) need to increase the number, distribution, competences and sustainability of HRH are identified in strategic objectives 2.3.8–2.3.10 (pp. 71–72) of SP1. Pay and incentives were addressed previously as part of the HTP.

The (continued) need to increase the number, distribution, competences and sustainability HRH are identified in strategic objective 2.8 (pp. 96–97) of SP2. Pay and incentives were addressed previously as part of the HTP.





4.12.2 Key systems are in place, and properly resourced, or there are plans for the improvements needed. This includes systems and capacity for planning and budgeting; technical and managerial supervision; and maintenance.

Administrative and managerial systems identified for strengthening and implementation initiated (Akdağ, 2012).

Objective 2.3 (and associated subobjectives) concerns the need to clarify the stewardship, regulator, planning and supervisory role of the Ministry of Health.

Key systems in place as a result of the previous HTP reforms and initiatives.

4.12.3 Strategy describes approaches to meet technical assistance requirements for its implementation.

No information about technical assistance needed.



13. Financial management and procurement arrangements are appropriate, compliant and accountable. Action plans to improve public financial management and procurement address weaknesses identified in the strategy and another diagnostic work.

4.13.1 Financial management (FM) system meets national and international standards, and produces reports appropriate for decision-making, oversight and analysis. Strengths and weaknesses in financial management systems, capacity, and practices in the sector are identified, drawing on other studies. Action plans to strengthen public FM address fiduciary risks are feasible within a reasonable timeframe and in fully costed.

FM system upgra-ded as part of HTP (Akdağ, 2012).

FM system upgraded as part of HTP (Akdağ, 2012).

FM system upgraded as part of HTP (Akdağ, 2012).

49




4.13.2 Procurement systems meet national and international standards. Areas requiring strengthening have been identified, drawing on other studies, and there is a realistic plan to address these.

Procurement system reformed and upgraded as part of HTP (Akdağ, 2012).



4.13.3 Reasonable assurance is provided by independent internal and external audits and by parliamentary oversight. Audits include assessment of value for money. Mechanisms are in place and functional.

Internal audit and control mechanisms reformed and upgraded as part of strategic control; findings used in Ministry of Health’s M&E processes and follow up actions taken, when necessary (Akdağ, 2012).

The establishment of a separate audit unit within the Ministry of Health was part of SP1, SO 2.3.

A separate Audit Services Unit was established in the Ministry of Health as part of the reorganization of the Ministry of Health (under SP1).

4.13.4 It is clear how funds and other resources will reach the intended beneficiaries, including modalities for channelling and reporting on external funds. There are systematic mechanisms to ensure timely disbursements, efficient flow of funds and to resolve bottlenecks. In decentralized health systems, this includes effective subnatio-nal fund flow processes and financial oversight.

Not a strategic issue for Turkey’s health sector. Furthermore, FM system and internal auditing system were upgraded as part of Strategic Control; a conditional cash transfer programme initiated in 2004 (Akdağ, 2012).







14. Governance, accountability, management and coordination mechanisms for implementation are specified.

4.14.1 Internal and multistakeholder external governance arrangements exist that specify management, oversight, coordination and reporting mechanisms for national strategy implementation.

No internal or multistakeholder external governance arrangements described, but not really applicable for Turkey.

No internal or multistakeholder external governance arrangements described but not really applicable for Turkey.

No internal or multistakeholder external governance arrangements described but not really applicable for Turkey.

4.14.2 Description of national policies relating to governance, accountability, oversight, enforcement and reporting mechanisms within the Ministry and relevant departments. Plans demonstrate how past issues and accountability in governance will be addressed, to fully comply with national regulations and international good practice.

There are internal audit and control mechanisms that have been reformed and upgraded as part of Strategic Control, applicable to the Ministry of Health, relevant departments, as well as relevant public administrations and private entities (Akdağ, 2012).

There are internal audit and control mechanisms that have been reformed and upgraded as part of Strategic Control, applicable to the Ministry of Health, relevant departments, as well as relevant public administrations and private entities (Akdağ, 2012). Addressed separately for Turkey as a whole in the context of European Union accession requirements (see, for example, European Commission, 2009).

There are internal audit and control mechanisms that have been reformed and upgraded as part of Strategic Control, applicable to the Ministry of Health, relevant departments, as well as relevant public administrations and private entities (Akdağ, 2012). Addressed separately for Turkey as a whole in the context of European Union accession requirements (see, for example, European Commission, 2009).

5. Monitoring, evaluation and review – Soundness of review and evaluation mechanisms and how the results are used.

15. The plan for M&E is sound, reflects the strategy and includes core indicators; sources of information; methods and responsibilities for data collection, management, analysis and quality assurance.

5.15.1 There is a comprehensive framework that guides the M&E work, which reflects the goals and objectives of the national strategy.

Comprehensive M&E framework implemented as part of Strategic Control (Akdağ, 2012).

Comprehensive M&E framework included in SP1, which reflects goals and objectives of SP1 (pp. 92–109 and 120–123).

Comprehensive M&E framework included in SP1, which reflects goals and objectives of SP2 (pp. 134-147 and 158–161).

51




5.15.2 There is a balanced and core set of indicators and targets to measure progress, equity and performance.

HTP established a Balanced Scorecard System and Score Performance Assessment System with 261 indicators (Akdağ, 2012).

HTP established a Balanced Scorecard System and Score Performance Assessment System; system continued updated in SP1.

HTP established a Balanced Scorecard System and Score Performance Assessment System; system continued updated in SP2.

5.15.3 The M&E plan specifies data sources and collection methods, identifies and addresses data gaps and defines information flows.

Data sources and collection methods identified as part of the Balanced Scorecard System (Akdağ, 2012).

Data sources and collection methods identified as part of the Balanced Scorecard System.

Data sources and collection methods identified as part of the Balanced Scorecard System.

5.15.4 Data analysis and synthesis is specified and data quality issues are anticipated and addressed.

Reporting requirements included under health information system, but detailed specification of data analysis and synthesis not included in Emergency Action Plan.

Reporting requirements included under M&E framework, but detailed specification of data analysis and synthesis not included in SP1.

Reporting requirements included under M&E framework, but although detailed specification of data analysis and synthesis were not included in SP2, the Strategic Plan M&E Programme has been developed and is also being used electronically.

5.15.5 Data disse-mination and communication is effective and regular, including analytical reports for performance reviews and data sharing.

A Decision Support System was established to prepare analyses, reports and statistics for health policy-makers, planners and decision-makers; 200 reports were produced (Ministry of Health, 2010a).

Regular reporting requirements included under M&E framework in SP1.

Regular reporting requirements included under M&E framework in SP2.

5.15.6 Roles and responsibilities in M&E are clearly defined, with a mechanism for coordination and plans for strengthening capacity.

Strategic Control includes roles and responsibilities for M&E activities. (Akdağ, 2012).

The strategic planning process for SP1 describes who is responsible for Strategic Control, including activities and outputs and responsible units (p. 26).

With the reorganization of the Ministry of Health, units with responsibility for M&E and analysis have been established (see p. 34).





16. There is a plan for joint periodic performance reviews and processes to feedback the findings into decision-making and action.

5.16.1 There is a multipartner review mechanism that inputs systematically into assessing sector or programme performance against annual and long-term goals.

Not relevant for Turkey, except as related to specific projects financed by external partners.



5.16.2 Regular assessments of progress and performance are used as a basis for policy dialogue and performance review.


Not relevant for Turkey, except as related to specific projects financed by external partner.


5.16.3 There are processes for identifying corrective measures and translating these into actions, including mechanisms to provide feedback to subnational levels and to adjust financial allocations.

This was an integral part of the Strategic Control System put in place by the HTP (Akdağ, 2012).

Part of the Strategic Control System in SP1. No information included about feedback mechanisms to subnational levels, but they are part of the M&E system. Similarly, mechanisms exist to adjust financial allocations as needed in response to review findings, but no explicit information about them contained in SP1.

Part of the Strategic Control System in SP2 No information included about feedback mechanisms to subnational levels, but they are part of the M&E system. Similarly, mechanisms exist to adjust financial allocations as needed in response to review findings; Moreover The Strategy Development Presidency of the Ministry of Health has been established to operate those mechanisms and processes.

abc These columns describe the aspects, attributes and criteria, respectively in JANS (IHP+, 2011). The column, No., consists of a three-part number: aspect, attribute

and criterion in JANS. Thus, 1.1.3 refers to criterion 3 of attribute 1, which belongs to aspect 1 (Situational analysis and programming) (IHP+, 2011).

d The page numbers in this column refer to the Strategic Plan 2010–2014 (Ministry of Health, 2010b) unless otherwise indicated.

e The page numbers in this column refer to the Strategic Plan 2013–2017 (Ministry of Health, 2012) unless otherwise indicated.

f SMARTER is an acronym for S (specific), M (measurable), A (audacious) (sic), (results focused), T (time bound), E (encompassing) and R (reviewed) (Ministry of

Health, 2010b).

53

REFERENCES9

Akdağ R (2010). Health Transformation Program in Turkey – Progress Report September 2010. Ankara: Ministry of Health (http://www.saglik.gov.tr/EN/dosya/2-1251/h/healthtransformationprogrammeinturkey.pdf).



European Commission. (2009). Turkey TR07-IB-FI-02, Gap Analysis Report, Activity 1.2. Brussels: European Commission.

IHP+ (2011). Joint Assessment of National Health Strategies and Plans – Joint Assessment Tool: the attributes of a sound national strategy. Version 2: September 2011. International Health Partnership (http://www.who.int/workforcealliance/knowledge/toolkit/24_1.pdf).

Ministry of Health (2010a). Health Transformation Program in Turkey – Progress Report, September 2010. Ankara: Ministry of Health. (http://www.saglik.gov.tr/EN/dosya/2-1251/h/healthtransformationprogrammeinturkey.pdf).

Ministry of Health (2010b). Strategic Plan 2010–2014. Ankara: Ministry of Health. (http://ekutuphane.sagem.gov.tr/kitap.php?id=240&k=strategic_plan_2010_2014).

Ministry of Health (2012). Strategic Plan 2013–2017. Ankara: Ministry of Health (http://www.sgb.saglik.gov.tr/content/files/stratejikplanEng/index.html).

Republic of Turkey (2012). Public Financial Management and Control Law No. 5018. Ankara: Republic of Turkey, Ministry of Finance, Strategy Development Unit. (http://www.sgb.gov.tr/Mevzuat/01.Kanun/Public%20Financial%20Management%20and%20Control%20Law%20No.%205018.pdf).

T.R. Prime Ministry, State Planning Organization (2000). Long Term Strategy and 8th Five Year Development Plan (2001–2005). Ankara: T.R. Prime Ministry, State Planning Organization.

T.R. Prime Ministry, State Planning Organization (2007). Ninth Development Plan 2007–2013. Ankara: T.R. Prime Ministry, State Planning Organization.

9 All websites were accessed on 16 December 2014.


UNDG (2000). Common Country Assessment – Turkey (2000). United Nations Development Group (http://www.undg.org/archive_docs/1737-Turkey_CCA.pdf).

WHO (2008). International Health Regulations, second edition. Geneva: World Health Organization (http://www.who.int/ihr/9789241596664/en/).

WHO Regional Office for Europe (1998). Health21 – health for all in the 21st century. Copenhagen: WHO Regional Office for Europe (http://www.euro.who.int/__data/assets/pdf_file/0003/88590/EHFA5-E.pdf).

WHO Regional Office for Europe (2008). The Tallinn Charter: Health Systems for Health and Wealth. Copenhagen: WHO Regional Office for Europe (http://www.euro.who.int/en/publications/policy-documents/tallinn-charter-health-systems-for-health-and-wealth).

WHO Regional Office for Europe (2012). Successful health system reforms: the case of Turkey. Copenhagen: WHO Regional Office for Europe.

WHO Regional Office for Europe (2013). Health 2020. A European policy framework and strategy for the 21st century. Copenhagen: WHO Regional Office for Europe (http://www.euro.who.int/en/health-topics/health-policy/health-2020-the-european-policy-for-health-and-well-being/publications/2013/health-2020-a-european-policy-framework-and-strategy-for-the-21st-century).

55

ANNEX 4. STRATEGIC PLAN 2013–2017

The ultimate goal of the Strategic Plan 2013–2017 is to protect and improve the health of the Turkish people in an equitable manner. Additional information from the plan is in Table 4.1.

Strategic goal Objective/Subobjective

1. To protect the individual and the community from health risks and foster healthy lifestyles

1.1 To develop healthy dietary habits, increase the level of physical activity, and reduce obesity

1.1.1 To change individual dietary and physical activity behaviours through health promotion programmes

1.1.2 To develop standards for identification, monitoring and treatment of overweight individuals

1.1.3 To facilitate healthier food choices

1.2 To sustain the fight against tobacco and to reduce the exposure to tobacco in the use of addictive substances

1.2.1 To prevent the use of tobacco and addictive substances through health promotion programmes

1.2.2 To improve governance in the fight against the use of tobacco and addictive substances

1.2.3 To improve smoking cessation services

1.2.4 To improve the provision of preventive, curative and rehabilitative services for other addictive substances

1.3 To develop health literacy to increase individuals’ responsibility for their health

1.3.1 To identify, monitor and increase the level of health literacy in the population

1.3.2 To strengthen communication efforts aimed at improving health literacy in the society

1.4 To raise awareness of reproductive health and encourage healthy behaviours

1.4.1 To change individuals’ behaviours through programmes and activities aimed at promoting reproductive health

1.4.2 To improve reproductive health services

1.4.3 To improve reproductive health services for abortions

1.4.4 To improve the effectiveness of pre-marital counselling services via intersectoral cooperation

1.5 To reduce the impact on health of public health emergencies and disasters

1.5.1 To strengthen disaster preparedness

1.5.2 To strengthen coordination during disasters

1.5.3 To improve service delivery during and after emergencies and disasters

1.6 To protect and promote the health and well-being of employees by improving occupational health

1.6.1 To increase employee and employer awareness of occupational health

1.6.2 To strengthen occupational disease surveillance

1.6.3 To improve the delivery of occupational health services

TABLE 4.1 STRATEGIC GOALS, OBJECTIVES AND SUBOBJECTIVES OF THE STRATEGIC PLAN 2013–2017



1.7 To mitigate the negative impact on health of environmental hazards

1.7.1 To increase public awareness of the negative health impact of environmental hazards

1.7.2 To cooperate with relevant agencies to reduce the risk of carbon monoxide poisoning

1.7.3 To reduce the negative impact of water, air and land pollution on environmental and human health

1.8 To carry out effective actions on social determinants of health by mainstreaming health in all policies

1.8.1 To establish policies and programmes that ensure health equity and that influence social determinants of health within the framework of multisectoral cooperation

1.8.2 To strengthen intersectoral cooperation in high-priority areas

1.9 To combat in monitor communicable diseases and risk factors

1.9.1 To organize training programmes and campaigns to promote general hygiene and hand washing

1.9.2 To strengthen the surveillance system for early diagnosis and management of communicable diseases.

1.9.3 To sustain and strengthen communicable and zoonotic disease control programmes

1.10 To reduce and monitor the incidence of noncommunicable diseases and risk factors

1.10.1 To raise awareness of noncommunicable diseases and risk factors

1.10.2 To establish a surveillance system to monitor and manage noncommunicable diseases

1.10.3 To strengthen the prevention and control programmes for noncommunicable diseases

2. To provide accessible, appropriate, effective, and efficient health services to individuals and the community

2.1 To improve the quality and safety of health services

2.1.1 To continue to improve health care services in terms of administration, structure and function

2.1.2 To improve the quality and safety of primary health care services

2.1.3 To improve the quality and safety of diagnostic and curative services

2.1.4 To improve the quality and safety of rehabilitation services

2.2 To protect and improve maternal, child, and adolescent health

2.2.1 To protect and improve maternal health

2.2.2 To protect and improve neonatal and infant health

2.2.3 To protect and improve child and adolescent health

2.3 To ensure the effective utilization of preventive and essential health services

2.3.1 To rollout the use of health promotion and healthy lifestyle programmes

2.3.2 To increase access to primary health care services

2.3.3 To increase the utilization of preventive dental care services

2.3.4 To improve preventive mental health services

2.3.5 To improve and expand the scope of cancer screening programmes

2.4 To sustain appropriate and timely access to emergency care services

2.4.1 To increase the proper use of emergency call services

57


2.4.2 To improve the emergency response system

2.4.3 To improve emergency care services in hospitals

2.4.4 To reduce the negative health impact of accidents, injuries, and poisonings

2.5 To improve the integration continuity of care by strengthening the role of primary health care

2.5.1 To improve the practice of family medicine

2.5.2 To strengthen the integration of other primary health care services into the family practice system

2.5.3 To strengthen the integration of family medicine into hospital on laboratory services

2.6 To control and reduce the complications of noncommunicable disease

2.6.1 To increase the awareness it of the importance of complications of noncommunicable diseases

2.6.2 To improve the quality of health care services for chronic diseases

2.7 To strengthen the regulations of traditional, complementary and alternative medical practices to ensure their effectiveness and safety

2.7.1 To develop evidence-based policies and programmes on traditional complementary and alternative medical practices

2.7.2 To improve the governance of evidence-based traditional, complementary and alternative medical practices

2.7.3 To improve the quality of traditional, complementary and alternative medical practices

2.8 To continue to improve the distribution, competences and motivation of human resources for health, and to ensure the sustainability of human resources for health

2.8.1 To improve the distribution of human resources for health

2.8.2 To increase the competence of human resources for health

2.8.3 To improve the motivation of human resources for health

2.8.4 To ensure the sustainability of human resources for health

2.9 To improve the capacity, quality and distribution of the health infrastructure and technologies and to ensure their sustainability

2.9.1 To improve the capacity, quality and distribution of the infrastructure of health care institutions

2.9.2 To improve the capacity, quality and distribution of health technology

2.10 To ensure accessibility, safety, efficacy and rational use of drugs, biological products and medical devices, and the safety of cosmetic products

2.10.1 To ensure that drugs, biological products and medical devices are of high quality, accessible and safe and efficient

2.10.2 To ensure the rational use of drugs and medical devices

2.10.3 To ensure the safety of cosmetic products

2.11 To enhance the health information systems for monitoring and evaluation of, and evidence-based decision-making for the health service delivery system

2.11.1 To improve the Turkish Health Information System which was established to collect health data in a joint database and share the data in a safe environment



2.11.2 To develop an Electronic Health Record system and a portal to collect, monitor and provide safe access to and sharing of personal health records

2.11.3 To establish data silos for the “Decision Support System” that has been established to plan health services and improve data mining practices

2.11.4 To improve health IT standards in order to increase e-health practices by service providers and users and to roll out e-health practices

2.11.5 To ensure the integration of health information systems into Health.Net and to roll it out to improve the quality and efficiency of service provision and to increase access to health services

2.11.6 To improve the quality and security standards for the people and institutions using the Health Information Systems

2.11.7 To improve the quality and security standards for the sector developing the Health Information Standards

2.11.8 To identify and implement the confidentiality, security and privacy principles for personal and institutional health records within the framework of information security and protection of personal privacy

3. To respond to the health needs and expectations of individuals based on people centred and holistic approach.

3.1 To strengthen the role of individuals in order to ensure their active participation in decisions regarding their health care

3.1.1 To increase the awareness among individuals of the need for their active participation in decisions regarding their health care

3.1.2 To initiate behaviour change among health care staff to encourage individuals to actively participate in decisions regarding their health care

3.1.3 To develop health communication channels to better respond to the needs and expectations of individuals

3.1.4 To better respond to the needs and expectations of individuals

3.2 To better meet the needs of individuals with special needs due to their physical, mental, social or economic conditions by ensuring easier access to appropriate health services

3.2.1 To improve health care services provided to disabled individuals

3.2.2 To improve the delivery of homecare services

3.2.3 To improve mental health care services

3.2.4 To improve health care services within the framework of gender equality and combat violence against women

3.2.5 To improve health care services for the elderly

3.2.6 To improve the health care services provided to individuals with low income

3.3 To contribute to ensuring equity in the financing of health services and protection of individuals from financial risks

3.3.1 To carry activities that contributes to ensuring equity in the financing of health care services

3.3.2 To improve the practices that protect individuals against impoverishment due to health expenses

3.4 To increase the satisfaction of individuals with their health services and that of health workers with their working conditions

3.4.1 To increase the level of satisfaction among patients and health care staff

59


4. To continue to develop the health sector as a means to contributing to the economic and social development of Turkey into global health

4.1 To maintain a financial sustainability of the health system without compromising service quality through implementation of evidence-based policies

4.1.1 To establish a dynamic structure that defines and problems in order to preserve the financial sustainability of the health system

4.1.2 To develop programmes and methods to ensure the optimum use of resources in order to maintain the financial sustainability the health system without compromising service quality

4.1.3 To monitor and assess programmes implemented to preserve the financial sustainability of health care services without compromising quality

4.1.4 To convert the payment system for Ministry of Health staff into an Outcome – Oriented Financing Model

4.2 To monitor health system performance and to document its contribution to health and the national economy

4.2.1 To develop, monitor and evaluate the performance measurement system for 2013–2017 Strategic Plan of the Ministry of Health

4.2.2 To develop and institutionalize the Turkish Health System Performance Assessment (THSPA).

4.2.3 To establish evidence for the contribution of health to the national economy

4.3 To promote research, development, and innovation in priority fields of the health sector

4.3.1 To develop support programmes to promote research, development and innovation in health

4.4 To foster the contribution of the health sector to the economy

4.4.1 To develop activity that will increase the contribution of the health sector to the economy

4.5 To strengthen health tourism in Turkey

4.5.1 To launch promotions and to become a destination centre for health tourism

4.5.2 To improve the quality of the service provision in health tourism

4.5.3 To expand the scope of health tourism services

4.5.4 To improve the health tourism governance

4.6 To be among the leaders in the development and implementation of global and regional health policies

4.6.1 To increase the capacity in global and regional health issues

4.6.2 To influence global and regional health priorities

4.6.3 To become a role model for other countries on the matters of international importance

4.7 To contribute to global health through cooperation and development aid

4.7.1 To increase the amount of humanitarian aid and development aid to countries in need of aid at the global and regional level

Source: Ministry of Health (2012). Strategic Plan 2013–2017. Ankara: Ministry of Health.

The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan Ukraine United Kingdom Uzbekistan WHOLIS number: e95429 Original: English

WHO Regional Office for EuropeUN City

Marmorvej 51DK-2100 Copenhagen Ø

DenmarkTel.: +45 45 33 70 00Fax: +45 45 33 70 01

Documents

Strategic planning for health: a case study from Turkey Strategic planning for health: a case study from Turkey PREFACE This report was prepared as part of the ongoing collaboration